INSTRUCTIONS This Passport Application Form FSM

INSTRUCTIONS
This Passport Application Form FSM-5001, must be filled out completely, signed and notarized
by the applicant at any notary public prior to submission to the FSM Passport Office. Please
print all information on this Application Form in Block Letters.
For new passport (new applicant) or renewal of expired passport, the following document is
required to be submitted with the Application Form FSM-5001.
New Passport (New Applicant)
o Court Registered Birth Certificate
o Two Identical Photographs of the applicant (size: 1 3/16 x 1 ¾)
o Registered Marriage Certificate is required for married name.
o In cases of unavailability of records of Birth Certificate, a court registered Baptismal
Certificate can be submitted with your application form.
o Payment of passport fee is payable to the FSM National Treasury in the amount of the
following fees schedule.
◊ $15.00 for Age 0 to 2 years old
◊ $25.00 for Age 3 to 17 years old
◊ $25.00 for Age 60 and older
◊ $50.00 for Age 18 to 59 years old
Passport Renewal
o The expired passport must be submitted with your Application Form FSM-5001
o Two Identical photographs of the applicant (size: 1 3/16 x 1 ¾)
o Payment of passport renewal fee is payable to the FSM National Treasury in the amount
as set above and is based on applicant’s current age.
Passport Replacement
a) A passport that is lost, stolen, damaged or mutilated may be replaced. Application for a
replacement shall be made by submitting an Application Form FSM-5001, the passport
itself if available, a sworn affidavit setting forth fully the circumstances surrounding the
loss, theft, damage or mutilation of the passport, the replacement fee in money order or
cashiers check payable to the FSM National Treasury, and two identical photographs of
the applicant. The Replacement fee shall be $75.00 for a regular adult passport, $50.00
for a regular children’s and senior citizens passport and $40.00 for a regular infant’s
passport.
b) A passport that has no remaining blank visa pages before the date of expiration may be
replaced. Application for a replacement shall be made by submitting an Application
Form FSM-5001, the passport, a fee of $25.00 in money order or cashiers check payable
to the FSM National Treasury and two identical photographs of the applicant.
c) A passport issued to an infant under 12 months may be replaced. Application for a
replacement shall be made by submitting an Application Form FSM-5001, the passport,
and two identical photographs of the applicant.
FSM FORM 5001B-REVISED FORM 5001A
FSM PASSPORT APPLICATION FORM
Applicant Photo
FOR OFFICIAL USE ONLY
Applicant must complete this form and forward it to the
Division of Immigration & Labor, Department of Justice,
FSM National Government, Palikir, Pohnpei FM 96941
Document Issued On: ______________
Issuing Official:___________________
1 3/16 x 1 ¾
PLEASE FOLLOW INSTRUCTIONS
Type of Passport: [ ] Ordinary [ ] Official [ ] Diplomatic
Applicant Information
Name: __________________________________
Last Name
______________________
Middle Initial
______________________________________
First Name
Other Names You Have Used:__________________________________________________________________________________
Date of Birth: ____________________ Gender
Height: ________________ Feet
[ ] Miss
_____________Inches
[ ] Mrs.
[ ] Ms.
[ ] Mr.
Hair Color___________ Eye Color ___________
Birth Place: ______________________________ Home Address:_______________________________________________________
Current Postal Address:_________________________________________________________________________________________
Have you ever been issued a foreign passport: [ ] Yes [ ] No
If yes, country of issuance, date issued and passport number____________________________________________________________
Basis of FSM citizen: [ ] Birth [ ] Naturalization [ ] Other means (Provide prove)
Father Information
Last Name:_________________________ First Name:_____________________________ Middle Name: ______________________
Birthdate:_________________________ Birthplace:_________________________ Is your father FSM citizen? [ ] Yes [ ] No
If no what nationality:________________________
Mother Information
Last Name:__________________________ First Name:_____________________________ Middle Name:______________________
Birthdate:_________________________ Birthplace:________________________ Is your mother FSM citizen? [ ] Yes [ ] No
If no what nationality:_____________________
Signature of Applicant Required (Do not sign in the box for infant and adult who cannot
Sign)
Please sign within the box. Signature must not touch line.
Signature of parent or guardian if under age 14 or unable to sign application._____________________________________________________________________
Subscribed and sworn to before me this ____________day of ______________ 20
S E A L
I hereby certify that I reviewed the application and found to be complete and I am satisfied that the applicant is a citizen of the Federated States of Micronesia, and
that he/she does not owe allegiance to any foreign country.
____________________________________
Reviewing Officer
_________________________
Date