Please complete and sign the statement below regarding your request for a second passport.

In view of the restrictive entry policies of one of the countries that I will be visiting, prolonged processing delays required to obtain a visa, or the need for multiple visas for my current travel, I am unable to complete my trip utilizing my current passport.

Consequently, I am requesting the issuance of a second passport to facilitate my travel to the countries provided on my passport application. I understand that one passport will be limited for four years and that I may reapply at the end of that period if my need to travel to the aforementioned countries continues.

Should either passport be lost or stolen, I will report the circumstances immediately to the Passport Office or the nearest U.S. Embassy/Consulate.

Please list the countries to be visited with approximate dates of travel:

NAME: _____________________________________________________

(Please Print Name Legibly)

SIGNATURE: ________________________________________________

DATE: _______________________________________________________

Page Updated:

4/25/24