EFTA00099203.pdf

Scanned Document Collection Page 1 of 3 Ly EL-7 APPLICATION FOR A U.S. PASSPORT BY MAIL Atter:p.:41 we !W. P.N04: c•-• Ga.?' 7+, ) C ' ,Ind:Wm lease elect the document (or documen• .) for , hkh you are applying: u 5. ;Sr • ••• e • , ee• •• em• e" 1. Name LdSt MAX11ELE rust S Mi&Pe u Li • Fed •'VS Evp '^ 7O/O CrIIISLAINE NOELLE 3. Se: O. Piece of Birth (OW a State or City & Canby as It IS ptatOal knOwl) OCIF MAISONS LAEICIE. FRANCE 6. Stalling Address: Riter/RiD • or PO &or 2. Date at Nit (mm410/ww.) S. Social &smote number NI 11 SoRK J State Zd Cede (Zp . 4 re /norm) 1000 7. Contact Phone Mgr it Er .n es re . (DP 114 1P:ers[ mermen: cc knit a :n Care Of or Gantry, 4 applgable 9. Have You Ever Used A Different H. m (leaden. Prraous Mmrupv. Levee, filar Chrge)7 1f tot *opt cony:deft. (Mao sokyne ropes I raffle) 10. Passport Soon of Passport Card MformatIon You mime as toted on year rodst Went passport or Mart Cant C M KC —pe.g. AI \ mAxv,r ii 3 'Scd-c Most retest pampas 000k a pastport card Imo date (wart/at14711) 12 04 2002 11. Name Cltomao Infonnation Caret! ', Mole as deflectif Mal MN pOSSpod book or passport card O Changed by Homage Mace dNan* Charge (Oly/SCOM) Dee (erraild•YM)') L. obi L, Court Order am • de au. .taiNct trd u a, d cat. to PPG.* VO .we .we C S. TO I AC 2 . SILIW SIGN IC DATE ' ^';:IC'1 Ile T1, Ci UN.% Al, EA St 1 OW I pan under wale/ Cl Non fal cf tae f011ernav 1): *mane/in or mamma estam d Ue urem scams and have rot arse aW U.S. clowns a manner. persannef any Cl the aet itiol order Mat a Coronas' ce tie merle We of tr.c al:Paton (unit% agiaratory natemem n mace** sratenseas made en Vie = no true and correct; 39 NR m¢l000nnpy and *duly Ma tease statements or needed Mere occumems re sup:ender% applatien; ape y. Po settaies•COMMOO 6 Ca lent. "WOO d rht; AM so ha* red and under/Med the ivarring co page mo Cl ow rdirucom eci the 00011000n This section toe SS* office only Range Certificate Date of Ramalle/Piace Issued: K Carl ads Date Aled/Coirt: K 00tr: O Attathen \ PPT fee_ 1C.. Et- Postage Doer C O ism C2811020)7 DS 82 02.20]8 ac /31 77" Page I d2 c-s era tea ...s.s LA, eta https://ccdi.state.osis.gov/p1s/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00099203 Scanned Document Collection Page 2 of 3 Name of Applicant i .1 • Fwy A Mae) Date of Birth (prortde./410 ) \1 \\\t:l. ‘ I . GIIISLAI \II \OFLI F I: ": •1 ii.6I 1111 12. Height 13. Hair Color 14. Eye Color 15. Occupation 16. Employer 9 , I NI \ [ It )0 \ i Huotts; IV • 1\1‘.‘1ko‘i ‘‘. 17. AdOltional • intact ho r No b . :c4 — _—_--- __, , . cell 1 ja Wort O I D wpm, 14. Permanent Address: Stner/Rf V • (No Y.O. 50‘) Wynn/ State hp Cede NU\ YORK N.1 10065 19. Emergency Contact • Provide the Sonnatona a pawn not oa*19 nen toy to be enacted In the no( Man omega's* Name Address: Street/9SO S or 9.0. Box or mite Gn State lip Code Phone Nutter RelalloMle0 20. Travel Plan Date of Trip (InneePrOPWV) tempt W 1/0 COMMIS to be view 06 I 1 100S I 4 MONTHS L.K . S. AFRICA. ISRAFI . I % N ta' \\ISI % \, IR %N. 7/ite 41 J (01- t /..1,0P,-,-- C blunt STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE 0 1 1.' I bv 80« - b ee-14 Pe& As- At/ est_ II HNNUINIIIIIIIIII a" — "Z-4/ e OS 02 10 20:0 2 Pave 2 o' I https://ccdi.state.osis.gov/p1s/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00099204 Scanned Document Collection Page 3 of 3 bit! ithOriZed Vvoen You fleet, It Fast - Since 1 981 Travisa Passport & Visa Service Letter of Authorization MEI 9,13008 di ] lAW ( •Joeli ast, r Made, Date of Birth: De(ernber a5, Place of Birth: ra,tauc 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 infomiaton may be released from U.S. Government files without prior written consent of the individual in question. Consequently, an employee of the U.S -cion t tency cannot disci .s the details of your passport application with Travis. Passport! 'ma wvire without yoiu. nen .ssior Please ^1,00,1” one of the gollOuann: -17 I authOnis P; sport/ lo -v to di -us any rohlor itch a arise .iith my passport appiostion voth Pubsport ... Vito dOINICy. 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 will b O ready for pock up. Signature) ca tV na Loa ad% https://ccdi.state.osis.gov/p1s/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00099205