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.