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DEPARTMENT

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APPLICATION

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LANKAN

PASSPORT,

EMERGENCY/IDENTITY

CERTIFICATE

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INI

APPLICATION

No.

APPLICATED

PASSPORT

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1. Type

Travel Document required

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All Countries

Middle East

Emergency

Countries Certificate

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Identity

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5. Surname

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6. Other Names

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7. Permanent Address Overseas

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8. Date

Birth

}

Date Month Year

9. Birth Certificate

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Number District

10. Place

Birth

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. Sex

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Female

Male

12. Profession/ Occupation/ Job

}

13. Have you obtained Citizenship

a foreign country or Dual Citizenship

Sri Lanka

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Yes

Yes,

Dual Citizenship

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14.

Mobile Phone No. Overseas

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15.

e-mail Address

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16. Foreign Nationality

17. Foreign Passport No.

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Father I Guardian

National Identity Card No. I Present Travel Document No.

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Mother I Guardian

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Client Undertaking

(Please cut off the inapplicable words)

I declare that I am a citizen

Sri Lanka

hold Dual Citizenship

Sri Lanka

am a citizen

..............................

(Write the name

the country}

I certify that I have not previously held

applied for any Passport, Emergency Certificate

an Identity Certificate

I certify that all previous passports, Emergency Certificate

an identity Certificates held by my name have been surrendered to the Sri Lankan Passport

Authorities for

cancellation, other than the passport/ Emergency Certfficate/ Identity Certificate No:

........................................

, which is now submitted and I have made no other application since the one attached was issued

me.

I certify that the information furnished in this application and documents attached

this application are true and correct and no alterations, modifications

falsifications ware carried out to hide

deflect true

facts.

I certify that affixed photographs are depicting the natural status

myself without disguise

concealment and were taken with

the last three months.

I Mr./MrsJMiss/Rev

................................................................................................................................................................

, residing at

............................................................

...............................................

applying

for

a passport through Sri Lanka Mission in

........................................................

, hereby undertake to provide

fingerprints to the Department prior to

departure from Sri Lanka. I

understand

the

failure

will

cause

passport

become

inactive,

preventing

departure

from

Sri

Lanka

..........................................................

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and

place

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Certificate Regrading the Applicant

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best

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the

infonnation given by the applicant is true

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the declamtion made above by the applicant is accumte.

The applicant placed his/her signature

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................................................

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Mission

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Special Reference

Controller I

BCALT/DE

PPTNo:

NIC DF/ Double (Different/ Same) PPT

lost

Yes/

Appearance (Different/ Under Age/ Above Age)

BCNo:

Black Listed: ID/ PPT/

or other reason District.

NIC/

PostaiiD

Ac's Signature

MCNo:

District:

Parents PPT copy/ NIC/ Consent Letter

Ac's Order:

&w>l Date/

;t;"llil

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