TRANSLATION
Please complete the Dutch application form
1 Details applicant
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
(maiden) name - write the full surname or for married women the surname at birth
First/given names (in full)
date of birth
place and country of birth
place and country of residence
Address (street – number)
Gender
male
female
unknown
height (in cm)
BSN number/Dutch tax number
application for
passport second passport
business passport
second business passport
identity card
emergency passport
laissez passer
2 Details of present travel document (passport and/or identity card)
2.1 number (passport)
date of issue
number (identity card)
date of issue
2.2 place of issue (passport)
place of issue (identity card)
2.3 If you cannot submit your travel document (passport and/or identity card), what is the reason:
3 Add name (former) partner in new travel document
NOTE : Only enter details in 3.1 to 3.5 if you wish to include the name of your (former/late) spouse
in your new passport/identity card
3.1 Marital status applicant
married
divorced
widow(er)
civil partnership
3.2 surname of spouse or partner
3.3 date and place of marriage/civil partnership
3.4 date and place of dissolution of marriage/civil partnership
3.5 reason for dissolution marriage/civil partnership
divorce
deceased annulment
dissolution civil partnership
other….
4 Questions regarding your nationality (need to be filled in by all applicants)
4.1 How did you acquire the Dutch nationality?
birth
marriage
naturalisation
otherwise, namely
4.2 Apart from the Dutch nationality, do you have another nationality?
no
yes, namely
Since|
4.3 If you answered question 4.2 with yes, how did you acquire the other nationality?
birth
marriage
naturalisation
otherwise, namely
4.4 Besides your Dutch passport, do you hold any other, foreign or Dutch travel documents?
no
yes, namely
5 If you are not residing in the Netherlands, fill in questions 5.1 to 5.6
5.1 Since when are you resident in this country?
5.2 Do you have a residence permit?
5.3 What was your last place of residence in the Netherlands?
5.4 In what year did you leave the Netherlands?
5.5 Did you de-register (‘uitschrijven’) in the Netherlands?
no
yes
5.6 Applicant remarks or comments
6
Signature applicant
I, the undersigned, hereby certify that the above information is correct and that the enclosed photographs are
a true image of myself. I also declare explicitly that I did not acquire another nationality by my own free will
or otherwise, thereby losing Netherlands nationality and that to the best of my knowledge I hold the
Netherlands nationality.
With the signing of this form I consent and agree that my data may be disclosed to other government
agencies for the purpose of determining the identity and nationality for the issuance of travel documents.
I am aware that fees paid are not refundable.
6.1
6.2
(place)
(signature of applicant)
(date)
If this application is made on behalf of a minor (under 18 years old), both parents (in case of joint custody) or
the custodian have/has to sign the application form, thereby giving consent to this application.
6.3
6.4
6.5
(place)
(name father/custodian)
(signature)
(date)
(name mother/custodian)
(signature)
This is not a formal passport application form.
No rights can be derived from this form.