EFTA00151152.pdf

Scanned Document Collection Page I of 3 APPLICATION FOR A U.S. PASSPORT BY MAIL 1111 11 1 L 'lease elect the document (or document ) for hien you are applying: U 3. -pc ., zo< 1. Name tast Un D , Ent ofC by s. -do/ o MAXWELL tint 6 name 2.Date et Lath Oran(Od/wW) GIIISLAINE NOELLL 1. Nett 4. Place of Birth (Oty& gat Or DRY Carty Mit 6 Cresol./ bar) S. END 6. Marling Adelmos: Mite( D • or PO 0, Undo t%3 Gy wire Lose (Do • .'Unarm) In Cat Of or Country, 4 appbcabie Las L S. JI 1F: ec rJ Er al re • RV "n4 9. Nave You Ever Used A Different Ni le (Marko Pre'0046 l'farnAdt. Le50 /N•wre C740,0.) 7 If sm. Nra rdmiNrAs (n , adUlen0 reign innsfas) 10. Passport book or Passport Card information Your name as mud on yar mod recent passport Cr paSSPON card COX GIIIG im N.01 i mAvA Ft I 3 V.,10 Most Welt Passport to* Cr pear card Issue date (nan/oid/ren) 1204 2002 4 t . 11. Harm Chang, Information • Conisitte than is Ofitoent thrill int "Upset beck or paSSpoir card Place of Name Change 00t/1 24(4) Date Onni0dOWY) ❑ Clanged by Menage j.., led s, Ccurt Order In de as.t Yr .vonce 1169 JI la rt Ot• to once yo aerie sans, •Lims c E TO PAC F. 2 YOU MUST SIGN inat TN'' C F':,:.041,7111, Al EA BAL,71.4 I Oars under sway 0 senor Meese Icattems. IN am a conn ix matter, newer el tee tinted Natti W nave acs. sere sal US otairthe co nateresty. reeormel any noun wed order 'Arts co Carders" cc the men, ode et ms *WOW (unless ex:ranaCers airtemennsecidxd); NetnentS made en Ire =n ere true md comet; 3g nave not IcsOmndiv and mealy made tent gsger wrents ar4 CrI m&dtd Ione onottoefid tger i t d aspacatiocr.41)the ptoator3g: woe end 0e rMumOa aowceoM I) a2yro Cr. r This section for Nmeing oaks only O menage Cerollate Date of Narnagertace Issued: O Cast Order Date Filediform; O Other: O Attached. PPT Fee_ 71. _ V_ Postage_ out &O a in•B d ommmomermvemmsmormm OS 82 10 2031 av 0582 0.22008 Page l d2 ac 71-C 7t1 AT 7* https://ccdi.state.osis.gov/p1s/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00151152 Scanned Document Collection Page 2 of 3 Name of Applicant an Fan 8 / Date of Birth &um 04310Y/ NI 1 Xi11 I I I Ali ls: \ I \ I \fll [ I I II 12. Height 13. Heir Color 14. Eye Color 15. Occupabon 16. Employer 'I -I M \ [ It ie. \ 1 14 la At \ It% ,, \ I „4r .‘ „ \- 1 17. Addltional • +gad ho 4 Nu to . lmwo, (-3 __ L I owe* o_ 18. Permanent Aderees: Sneer/RFD 0 (No Pa For) a unit a cy State Zp C004 19. Emergency Contact Prover the ethernebon damsel not esteem sit ov to be contacted el the men, Wan mmegency. Nam. Address: Street/RFD • a P0. Box Cr unit a City State Zp Cade Phone Number RelatiCtistip L 'L 20. Travel Plan Date of Trip (mnyekf/Yele tereth 0 DP totems to be esitee 06 I t ?D0R 4 MO\ III\ l K . S AFRICA. ISR \II . I \I . 11(,ll '1 4/ \ IS I \`..., IR \\ 7lles i'l Cf... , /„ 44.f.ra c Aisle C — /Z -V STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE ?,.,Mel - b el- /4. i 011- 1 / /b, tµ A. red est IIIIIIIIIIIIIIIIIII DS G210 20). 2 Page 2 a2 https://ccdi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hashr42994A0... 2/24/2020 EFTA00151153 Scanned Document Collection Page 3 of 3 Vsnen You sleet. h Fast Since 1 981 Travisa Passport & Visa Service ca Letter of Authorization Cs N3 oa i4L1 ae tea I a. el Date of Birth Place of Birth- I AUTHORIZE TRAVISA PASSPORT & VISA SERVICE TO SUBMIT MY PASSPORT APPLICATION TO A U.S. PASSPORT AGENCY, AND TO ACCEPT DELIVERY OF THE PASSPORT ON MY BEHALF. Under the provisions of the Pnvacy Act of 1974 (Public Law 93-579,) no information may be released from U.S. Government files without prior written consent of the individual in question. Consequently, an employee of the U.S - con t loncy cannot disci .s the details of your passport application with Ttaylsa Pa4sport t /ma tree° witenut yo. t nen .ssion Please ^4005,,, one of the follow•'^n: 1authorize P; spins! i le •v to di •.us any rohlor Ace ta arise ith my passport appecation with ...visa Pesvpon ... Vis. oerVICe. I want the U.S. Passport Agency to contact me directly should a problem anse with my PasspOrt application which concerns matters other than the date on which the passport vnll be ready for pick up. Signature) https://ccdi.state.osis.gov/p1s/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00151154