apply.pass-travel-usa.com
Open in
urlscan Pro
2606:4700:3032::ac43:c933
Public Scan
Submitted URL: http://apply.pass-travel-usa.com/
Effective URL: https://apply.pass-travel-usa.com/passport-v3
Submission: On January 23 via api from US — Scanned from US
Effective URL: https://apply.pass-travel-usa.com/passport-v3
Submission: On January 23 via api from US — Scanned from US
Form analysis 1 forms found in the DOM
POST https://apply.pass-travel-usa.com/passport-v3
<form action="https://apply.pass-travel-usa.com/passport-v3" method="post" id="passport-form">
<input type="hidden" name="_token" value="TYhee8CT1VbFJiwiCutjuDtXKnRHSHJYX2g37bcD">
<div class="card mt-3">
<div class="card-header ssn_row">
<h5 class="mb-0 ssn_start_here p-2">Start Here:</h5>
<h5 class="mb-0 p-2"> Service Type</h5>
</div>
<div class="card-body">
<div class="form-group row mb-0">
<div class="col-sm-4 col-form-label">
<label for="type">Select Service</label>
<span class="badge badge-secondary" style="cursor:pointer;position:relative;top:-2px;" data-toggle="tooltip" data-html="true"
data-original-title="<div class='text-left'>Our service offers a four-step process to help you apply for your passport. First, you'll fill out the online form. Second, we provide you with personalized instructions on the submission process. Third, you'll submit your form, and fourth, given all requirements are met, your new passport will be mailed to you by the state office. Our ongoing support is available for any questions or issues.</div>">What's
Included?</span>
</div>
<div class="col-sm-8">
<select class="form-control" id="type" name="type" required="">
<option value="3">New Passport </option>
<option value="4">Renewal Passport </option>
<option value="5">Lost/Stolen Passport </option>
</select>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">About the Applicant</h5>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Please select the document(s) you are applying for</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="applying_for" id="applying_for_book" value="1" required="">
<label class="form-check-label" for="applying_for_book"> Passport Book </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="applying_for" id="applying_for_card" value="2" required="">
<label class="form-check-label" for="applying_for_card"> Passport Card </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="applying_for" id="applying_for_both" value="3" required="">
<label class="form-check-label" for="applying_for_both"> Both </label>
</div>
</div>
</div>
</fieldset>
<div class="applying_for_passportbook" style="display:none;">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label"> Do you need a regular or large passport book?<br>
<small class="text-muted">Large passport book is recommended for Frequent Travelers. There is no additional fee.</small>
</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="passport_book_type" id="passport_book_type_regular" value="1">
<label class="form-check-label" for="passport_book_type_regular"> Regular </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="passport_book_type" id="passport_book_type_large" value="2">
<label class="form-check-label" for="passport_book_type_large"> Large </label>
</div>
</div>
</div>
</fieldset>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Gender</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="gender-male" value="male" required="">
<label class="form-check-label" for="gender-male"> Male </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="gender" id="gender-female" value="female" required="">
<label class="form-check-label" for="gender-female"> Female </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row first-name">
<label for="first-name" class="col-sm-4 col-form-label">First Name</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="first-name" name="first_name" value="" required="">
</div>
</div>
<div class="form-group row middle-name">
<label for="middle-name" class="col-sm-4 col-form-label">Middle Name <span class="text-muted">(Optional)</span></label>
<div class="col-sm-8">
<input type="text" class="form-control" id="middle-name" name="middle_name" value="">
</div>
</div>
<div class="form-group row last-name">
<label for="last-name" class="col-sm-4 col-form-label">Last Name</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="last-name" name="last_name" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="dob-year" class="col-sm-4 col-form-label">Date of Birth</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="dob-year" name="year_of_birth" required="">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="dob-month" name="month_of_birth" required="">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="dob-day" name="day_of_birth" required="">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="city-birth" class="col-sm-4 col-form-label">City of Birth</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="city-birth" name="city_birth" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="country-birth" class="col-sm-4 col-form-label">Country of Birth</label>
<div class="col-sm-8">
<select class="form-control" id="country-birth" name="country_birth" required="">
<option value="" disabled="" selected="">Select country</option>
<option value="US"> United States </option>
<option value="AF"> Afghanistan </option>
<option value="AX"> Akrotiri Sovereign Base Area </option>
<option value="AL"> Albania </option>
<option value="AG"> Algeria </option>
<option value="AN"> Andorra </option>
<option value="AO"> Angola </option>
<option value="AV"> Anguilla </option>
<option value="AY"> Antarctica </option>
<option value="AC"> Antigua And Barbuda </option>
<option value="AR"> Argentina </option>
<option value="AM"> Armenia </option>
<option value="AA"> Aruba </option>
<option value="AT"> Ashmore And Cartier Islands </option>
<option value="AS"> Australia </option>
<option value="AU"> Austria </option>
<option value="AJ"> Azerbaijan </option>
<option value="BF"> Bahamas </option>
<option value="BA"> Bahrain </option>
<option value="FQ"> Baker Island </option>
<option value="BG"> Bangladesh </option>
<option value="BB"> Barbados </option>
<option value="BO"> Belarus </option>
<option value="BE"> Belgium </option>
<option value="BH"> Belize </option>
<option value="BN"> Benin </option>
<option value="BD"> Bermuda </option>
<option value="BT"> Bhutan </option>
<option value="BL"> Bolivia </option>
<option value="BK"> Bosnia And Herzegovina </option>
<option value="BC"> Botswana </option>
<option value="BV"> Bouvet Island </option>
<option value="BR"> Brazil </option>
<option value="IO"> British Indian Ocean Territory </option>
<option value="BX"> Brunei </option>
<option value="BU"> Bulgaria </option>
<option value="UV"> Burkina Faso </option>
<option value="BM"> Burma </option>
<option value="BY"> Burundi </option>
<option value="CB"> Cambodia </option>
<option value="CM"> Cameroon </option>
<option value="CA"> Canada </option>
<option value="CV"> Cape Verde </option>
<option value="CJ"> Cayman Islands </option>
<option value="CT"> Central African Republic </option>
<option value="CD"> Chad </option>
<option value="CI"> Chile </option>
<option value="CH"> China </option>
<option value="KT"> Christmas Island </option>
<option value="IP"> Clipperton Island </option>
<option value="CK"> Cocos Keeling Islands </option>
<option value="CO"> Colombia </option>
<option value="CN"> Comoros </option>
<option value="CF"> Congo Brazzaville </option>
<option value="CG"> Congo Kinshasa </option>
<option value="CW"> Cook Islands </option>
<option value="CR"> Coral Sea Islands </option>
<option value="CS"> Costa Rica </option>
<option value="IV"> Cote D Ivoire </option>
<option value="HR"> Croatia </option>
<option value="CU"> Cuba </option>
<option value="CY"> Cyprus </option>
<option value="EZ"> Czech Republic </option>
<option value="DA"> Denmark </option>
<option value="DX"> Dhekelia Sovereign Base Area </option>
<option value="DJ"> Djibouti </option>
<option value="DO"> Dominica </option>
<option value="DR"> Dominican Republic </option>
<option value="TT"> East Timor </option>
<option value="EC"> Ecuador </option>
<option value="EG"> Egypt </option>
<option value="ES"> El Salvador </option>
<option value="EK"> Equatorial Guinea </option>
<option value="ER"> Eritrea </option>
<option value="EN"> Estonia </option>
<option value="ET"> Ethiopia </option>
<option value="FK"> Falkland Islands Islas Malvinas </option>
<option value="FO"> Faroe Islands </option>
<option value="FJ"> Fiji </option>
<option value="FI"> Finland </option>
<option value="FR"> France </option>
<option value="FP"> French Polynesia </option>
<option value="FS"> French Southern And Antarctic Lands </option>
<option value="GB"> Gabon </option>
<option value="GA"> Gambia </option>
<option value="GG"> Georgia </option>
<option value="GM"> Germany </option>
<option value="GH"> Ghana </option>
<option value="GI"> Gibraltar </option>
<option value="GR"> Greece </option>
<option value="GL"> Greenland </option>
<option value="GJ"> Grenada </option>
<option value="GT"> Guatemala </option>
<option value="GK"> Guernsey </option>
<option value="GV"> Guinea </option>
<option value="PU"> Guinea Bissau </option>
<option value="GY"> Guyana </option>
<option value="HA"> Haiti </option>
<option value="HM"> Heard Island And Mcdonald Islands </option>
<option value="VT"> Holy See </option>
<option value="HO"> Honduras </option>
<option value="HK"> Hong Kong </option>
<option value="HQ"> Howland Island </option>
<option value="HU"> Hungary </option>
<option value="IC"> Iceland </option>
<option value="IN"> India </option>
<option value="ID"> Indonesia </option>
<option value="IR"> Iran </option>
<option value="IZ"> Iraq </option>
<option value="EI"> Ireland </option>
<option value="IM"> Isle Of Man </option>
<option value="IS"> Israel </option>
<option value="IT"> Italy </option>
<option value="JM"> Jamaica </option>
<option value="JN"> Jan Mayen </option>
<option value="JA"> Japan </option>
<option value="DQ"> Jarvis Island </option>
<option value="JE"> Jersey </option>
<option value="JQ"> Johnston Atoll </option>
<option value="JO"> Jordan </option>
<option value="KZ"> Kazakhstan </option>
<option value="KE"> Kenya </option>
<option value="KQ"> Kingman Reef </option>
<option value="KR"> Kiribati </option>
<option value="KN"> Korea North </option>
<option value="KS"> Korea South </option>
<option value="KU"> Kuwait </option>
<option value="KG"> Kyrgyzstan </option>
<option value="LA"> Laos </option>
<option value="LG"> Latvia </option>
<option value="LE"> Lebanon </option>
<option value="LT"> Lesotho </option>
<option value="LI"> Liberia </option>
<option value="LY"> Libya </option>
<option value="LS"> Liechtenstein </option>
<option value="LH"> Lithuania </option>
<option value="LU"> Luxembourg </option>
<option value="MC"> Macau </option>
<option value="MK"> Macedonia </option>
<option value="MA"> Madagascar </option>
<option value="MI"> Malawi </option>
<option value="MY"> Malaysia </option>
<option value="MV"> Maldives </option>
<option value="ML"> Mali </option>
<option value="MT"> Malta </option>
<option value="RM"> Marshall Islands </option>
<option value="MR"> Mauritania </option>
<option value="MP"> Mauritius </option>
<option value="MF"> Mayotte </option>
<option value="MX"> Mexico </option>
<option value="FM"> Micronesia Federated States Of </option>
<option value="MQ"> Midway Islands </option>
<option value="MD"> Moldova </option>
<option value="MN"> Monaco </option>
<option value="MG"> Mongolia </option>
<option value="MJ"> Montenegro </option>
<option value="MH"> Montserrat </option>
<option value="MO"> Morocco </option>
<option value="MZ"> Mozambique </option>
<option value="WA"> Namibia </option>
<option value="NR"> Nauru </option>
<option value="BQ"> Navassa Island </option>
<option value="NP"> Nepal </option>
<option value="NL"> Netherlands </option>
<option value="NT"> Netherlands Antilles </option>
<option value="NC"> New Caledonia </option>
<option value="NZ"> New Zealand </option>
<option value="NU"> Nicaragua </option>
<option value="NG"> Niger </option>
<option value="NI"> Nigeria </option>
<option value="NE"> Niue </option>
<option value="NF"> Norfolk Island </option>
<option value="CQ"> Northern Mariana Islands </option>
<option value="NO"> Norway </option>
<option value="MU"> Oman </option>
<option value="PK"> Pakistan </option>
<option value="PS"> Palau </option>
<option value="LQ"> Palmyra Atoll </option>
<option value="PM"> Panama </option>
<option value="PP"> Papua New Guinea </option>
<option value="PF"> Paracel Islands </option>
<option value="PA"> Paraguay </option>
<option value="PE"> Peru </option>
<option value="RP"> Philippines </option>
<option value="PC"> Pitcairn Islands </option>
<option value="PL"> Poland </option>
<option value="PO"> Portugal </option>
<option value="QA"> Qatar </option>
<option value="RO"> Romania </option>
<option value="RS"> Russia </option>
<option value="RW"> Rwanda </option>
<option value="SH"> Saint Helena </option>
<option value="SC"> Saint Kitts And Nevis </option>
<option value="ST"> Saint Lucia </option>
<option value="SB"> Saint Pierre And Miquelon </option>
<option value="VC"> Saint Vincent And Grenadines </option>
<option value="WS"> Samoa </option>
<option value="SM"> San Marino </option>
<option value="TP"> Sao Tome And Principe </option>
<option value="SA"> Saudi Arabia </option>
<option value="SG"> Senegal </option>
<option value="RB"> Serbia </option>
<option value="SE"> Seychelles </option>
<option value="SL"> Sierra Leone </option>
<option value="SN"> Singapore </option>
<option value="LO"> Slovakia </option>
<option value="SI"> Slovenia </option>
<option value="BP"> Solomon Islands </option>
<option value="SO"> Somalia </option>
<option value="SF"> South Africa </option>
<option value="SX"> South Georgia And South Sandwich Islands </option>
<option value="SP"> Spain </option>
<option value="PG"> Spratly Islands </option>
<option value="CE"> Sri Lanka </option>
<option value="SU"> Sudan </option>
<option value="NS"> Suriname </option>
<option value="SV"> Svalbard </option>
<option value="WZ"> Swaziland </option>
<option value="SW"> Sweden </option>
<option value="SZ"> Switzerland </option>
<option value="SY"> Syria </option>
<option value="TW"> Taiwan </option>
<option value="TI"> Tajikistan </option>
<option value="TZ"> Tanzania </option>
<option value="TH"> Thailand </option>
<option value="TO"> Togo </option>
<option value="TL"> Tokelau </option>
<option value="TN"> Tonga </option>
<option value="TD"> Trinidad And Tobago </option>
<option value="TS"> Tunisia </option>
<option value="TU"> Turkey </option>
<option value="TX"> Turkmenistan </option>
<option value="TK"> Turks And Caicos Islands </option>
<option value="TV"> Tuvalu </option>
<option value="UG"> Uganda </option>
<option value="UP"> Ukraine </option>
<option value="AE"> United Arab Emirates </option>
<option value="UK"> United Kingdom </option>
<option value="UY"> Uruguay </option>
<option value="UZ"> Uzbekistan </option>
<option value="NH"> Vanuatu </option>
<option value="VE"> Venezuela </option>
<option value="VM"> Vietnam </option>
<option value="VI"> Virgin Islands British </option>
<option value="WQ"> Wake Island </option>
<option value="WF"> Wallis And Futuna </option>
<option value="WI"> Western Sahara </option>
<option value="YM"> Yemen </option>
<option value="ZA"> Zambia </option>
<option value="ZI"> Zimbabwe </option>
</select>
</div>
</div>
<div class="form-group row state-birth-field" style="display: none;">
<label for="state-birth" class="col-sm-4 col-form-label">State of Birth</label>
<div class="col-sm-8">
<select class="form-control" id="state-birth" name="state_birth">
<option value="" disabled="" selected="">Select state</option>
<option value="AL"> Alabama </option>
<option value="AK"> Alaska </option>
<option value="AZ"> Arizona </option>
<option value="AR"> Arkansas </option>
<option value="CA"> California </option>
<option value="CO"> Colorado </option>
<option value="CT"> Connecticut </option>
<option value="DE"> Delaware </option>
<option value="DC"> District Of Columbia </option>
<option value="FL"> Florida </option>
<option value="GA"> Georgia </option>
<option value="HI"> Hawaii </option>
<option value="ID"> Idaho </option>
<option value="IL"> Illinois </option>
<option value="IN"> Indiana </option>
<option value="IA"> Iowa </option>
<option value="KS"> Kansas </option>
<option value="KY"> Kentucky </option>
<option value="LA"> Louisiana </option>
<option value="ME"> Maine </option>
<option value="MD"> Maryland </option>
<option value="MA"> Massachusetts </option>
<option value="MI"> Michigan </option>
<option value="MN"> Minnesota </option>
<option value="MS"> Mississippi </option>
<option value="MO"> Missouri </option>
<option value="MT"> Montana </option>
<option value="NE"> Nebraska </option>
<option value="NV"> Nevada </option>
<option value="NH"> New Hampshire </option>
<option value="NJ"> New Jersey </option>
<option value="NM"> New Mexico </option>
<option value="NY"> New York </option>
<option value="NC"> North Carolina </option>
<option value="ND"> North Dakota </option>
<option value="OH"> Ohio </option>
<option value="OK"> Oklahoma </option>
<option value="OR"> Oregon </option>
<option value="PA"> Pennsylvania </option>
<option value="RI"> Rhode Island </option>
<option value="SC"> South Carolina </option>
<option value="SD"> South Dakota </option>
<option value="TN"> Tennessee </option>
<option value="TX"> Texas </option>
<option value="UT"> Utah </option>
<option value="VT"> Vermont </option>
<option value="VA"> Virginia </option>
<option value="WA"> Washington </option>
<option value="WV"> West Virginia </option>
<option value="WI"> Wisconsin </option>
<option value="WY"> Wyoming </option>
<option value="AS"> American Samoa </option>
<option value="FM"> Federated States Of Micronesia </option>
<option value="GU"> Guam </option>
<option value="MH"> Marshall Islands </option>
<option value="MP"> Northern Mariana Islands </option>
<option value="PW"> Palau </option>
<option value="PR"> Puerto Rico </option>
<option value="VI"> Virgin Islands </option>
<option value="AE"> Armed Forces Middle East </option>
<option value="AA"> Armed Forces Americas </option>
<option value="AP"> Armed Forces Pacific </option>
</select>
</div>
</div>
<div class="form-group row ss-number">
<label for="ss-number-1" class="col-sm-4 col-form-label"> Social Security Number <small class="form-text text-muted"><img src="/images/image_secure.png" alt="Secure" style="vertical-align:middle;display:inline-block;margin-right:5px;"> Please
confirm your SSN so that it is accurate. Your SSN is secured by latest SSL technology.</small>
</label>
<div class="col-sm-2 mb-1 w-25">
<input type="number" class="form-control ssn_numeric_field" id="ss-number-1" name="ssn_1" min="0" max="999" maxlength="3" value="" required="">
</div>
<div class="col-sm-2 mb-1 w-25">
<input type="number" class="form-control ssn_numeric_field" id="ss-number-2" name="ssn_2" min="0" max="99" maxlength="2" value="" required="">
</div>
<div class="col-sm-2 mb-1 w-25">
<input type="number" class="form-control ssn_numeric_field" id="ss-number-3" name="ssn_3" min="0" max="9999" maxlength="4" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="height-in" class="col-sm-4 col-form-label">Height</label>
<div class="col-sm-4 mb-1">
<label for="height-ft" class="col-form-label">Feet</label>
<select class="form-control" id="height-ft" name="height_ft" placeholder="Feet" required="">
<option value="" disabled="" selected="">Select Height (ft.)</option>
<option value="0"> 0 </option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
</select>
</div>
<div class="col-sm-4 mb-1">
<label for="height-in" class="col-form-label">Inches</label>
<select class="form-control" id="height-in" name="height_in" placeholder="Inches" required="">
<option value="" disabled="" selected="">Select Height (In.)</option>
<option value="0"> 0 </option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="hair-color" class="col-sm-4 col-form-label">Hair Color</label>
<div class="col-sm-8 mb-1">
<select class="form-control" id="hair-color" name="hair_color" placeholder="Hair Color" required="">
<option value="" disabled="" selected="">Select Hair Color</option>
<option value="1"> Black </option>
<option value="2"> Blonde </option>
<option value="3"> Brown </option>
<option value="4"> Red </option>
<option value="5"> Gray </option>
<option value="6"> Other </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="eye-color" class="col-sm-4 col-form-label">Eye Color</label>
<div class="col-sm-8 mb-1">
<select class="form-control" id="eye-color" name="eye_color" placeholder="Eye Color" required="">
<option value="" disabled="" selected="">Select Eye Color</option>
<option value="1"> Amber </option>
<option value="2"> Black </option>
<option value="3"> Blue </option>
<option value="4"> Brown </option>
<option value="5"> Gray </option>
<option value="6"> Green </option>
<option value="7"> Hazel </option>
</select>
</div>
</div>
<div class="form-group row occupation">
<label for="occupation" class="col-sm-4 col-form-label">Occupation</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="occupation" name="occupation" value="" required="">
</div>
</div>
<div class="form-group row employer-school">
<label for="employer-school" class="col-sm-4 col-form-label"> Employer/School <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="employer-school" name="employer_or_school" value="">
</div>
</div>
<div class="form-group row other-name-1">
<label for="other-name-1" class="col-sm-4 col-form-label"> Former Name <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="other-name-1" name="former_name_a" value="">
<small class="form-text text-muted">List any other names you have used such as Birth Name, Maiden, Previous Marriage, or Legal Name Change. Only enter the name that was different.</small>
</div>
</div>
<div class="form-group row other-name-2">
<label for="other-name-2" class="col-sm-4 col-form-label"> Former Name <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="other-name-2" name="former_name_b" value="">
<small class="form-text text-muted">List any other names you have used such as Birth Name, Maiden, Previous Marriage, or Legal Name Change. Only enter the name that was different.</small>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Contact Information</h5>
<p class="mb-0 text-muted">Where should the passport be mailed?</p>
</div>
<div class="card-body">
<div class="form-group row">
<label for="s2_street_address1" class="col-sm-4 col-form-label">Street Address/RFD#, PO Box, or URB</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_street_address1" name="mailing_address_1" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="s2_street_address2" class="col-sm-4 col-form-label">Street Address 2 (Include Apartment, Suite, etc)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_street_address2" name="mailing_address_2" value="">
</div>
</div>
<div class="form-group row">
<label for="s2_city" class="col-sm-4 col-form-label">City</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_city" name="mailing_city" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="s2_country" class="col-sm-4 col-form-label">Country</label>
<div class="col-sm-8">
<select class="form-control" id="s2_country" name="mailing_country" required="">
<option value="" disabled="" selected="">Select country</option>
<option value="US"> United States </option>
<option value="AF"> Afghanistan </option>
<option value="AX"> Akrotiri Sovereign Base Area </option>
<option value="AL"> Albania </option>
<option value="AG"> Algeria </option>
<option value="AN"> Andorra </option>
<option value="AO"> Angola </option>
<option value="AV"> Anguilla </option>
<option value="AY"> Antarctica </option>
<option value="AC"> Antigua And Barbuda </option>
<option value="AR"> Argentina </option>
<option value="AM"> Armenia </option>
<option value="AA"> Aruba </option>
<option value="AT"> Ashmore And Cartier Islands </option>
<option value="AS"> Australia </option>
<option value="AU"> Austria </option>
<option value="AJ"> Azerbaijan </option>
<option value="BF"> Bahamas </option>
<option value="BA"> Bahrain </option>
<option value="FQ"> Baker Island </option>
<option value="BG"> Bangladesh </option>
<option value="BB"> Barbados </option>
<option value="BO"> Belarus </option>
<option value="BE"> Belgium </option>
<option value="BH"> Belize </option>
<option value="BN"> Benin </option>
<option value="BD"> Bermuda </option>
<option value="BT"> Bhutan </option>
<option value="BL"> Bolivia </option>
<option value="BK"> Bosnia And Herzegovina </option>
<option value="BC"> Botswana </option>
<option value="BV"> Bouvet Island </option>
<option value="BR"> Brazil </option>
<option value="IO"> British Indian Ocean Territory </option>
<option value="BX"> Brunei </option>
<option value="BU"> Bulgaria </option>
<option value="UV"> Burkina Faso </option>
<option value="BM"> Burma </option>
<option value="BY"> Burundi </option>
<option value="CB"> Cambodia </option>
<option value="CM"> Cameroon </option>
<option value="CA"> Canada </option>
<option value="CV"> Cape Verde </option>
<option value="CJ"> Cayman Islands </option>
<option value="CT"> Central African Republic </option>
<option value="CD"> Chad </option>
<option value="CI"> Chile </option>
<option value="CH"> China </option>
<option value="KT"> Christmas Island </option>
<option value="IP"> Clipperton Island </option>
<option value="CK"> Cocos Keeling Islands </option>
<option value="CO"> Colombia </option>
<option value="CN"> Comoros </option>
<option value="CF"> Congo Brazzaville </option>
<option value="CG"> Congo Kinshasa </option>
<option value="CW"> Cook Islands </option>
<option value="CR"> Coral Sea Islands </option>
<option value="CS"> Costa Rica </option>
<option value="IV"> Cote D Ivoire </option>
<option value="HR"> Croatia </option>
<option value="CU"> Cuba </option>
<option value="CY"> Cyprus </option>
<option value="EZ"> Czech Republic </option>
<option value="DA"> Denmark </option>
<option value="DX"> Dhekelia Sovereign Base Area </option>
<option value="DJ"> Djibouti </option>
<option value="DO"> Dominica </option>
<option value="DR"> Dominican Republic </option>
<option value="TT"> East Timor </option>
<option value="EC"> Ecuador </option>
<option value="EG"> Egypt </option>
<option value="ES"> El Salvador </option>
<option value="EK"> Equatorial Guinea </option>
<option value="ER"> Eritrea </option>
<option value="EN"> Estonia </option>
<option value="ET"> Ethiopia </option>
<option value="FK"> Falkland Islands Islas Malvinas </option>
<option value="FO"> Faroe Islands </option>
<option value="FJ"> Fiji </option>
<option value="FI"> Finland </option>
<option value="FR"> France </option>
<option value="FP"> French Polynesia </option>
<option value="FS"> French Southern And Antarctic Lands </option>
<option value="GB"> Gabon </option>
<option value="GA"> Gambia </option>
<option value="GG"> Georgia </option>
<option value="GM"> Germany </option>
<option value="GH"> Ghana </option>
<option value="GI"> Gibraltar </option>
<option value="GR"> Greece </option>
<option value="GL"> Greenland </option>
<option value="GJ"> Grenada </option>
<option value="GT"> Guatemala </option>
<option value="GK"> Guernsey </option>
<option value="GV"> Guinea </option>
<option value="PU"> Guinea Bissau </option>
<option value="GY"> Guyana </option>
<option value="HA"> Haiti </option>
<option value="HM"> Heard Island And Mcdonald Islands </option>
<option value="VT"> Holy See </option>
<option value="HO"> Honduras </option>
<option value="HK"> Hong Kong </option>
<option value="HQ"> Howland Island </option>
<option value="HU"> Hungary </option>
<option value="IC"> Iceland </option>
<option value="IN"> India </option>
<option value="ID"> Indonesia </option>
<option value="IR"> Iran </option>
<option value="IZ"> Iraq </option>
<option value="EI"> Ireland </option>
<option value="IM"> Isle Of Man </option>
<option value="IS"> Israel </option>
<option value="IT"> Italy </option>
<option value="JM"> Jamaica </option>
<option value="JN"> Jan Mayen </option>
<option value="JA"> Japan </option>
<option value="DQ"> Jarvis Island </option>
<option value="JE"> Jersey </option>
<option value="JQ"> Johnston Atoll </option>
<option value="JO"> Jordan </option>
<option value="KZ"> Kazakhstan </option>
<option value="KE"> Kenya </option>
<option value="KQ"> Kingman Reef </option>
<option value="KR"> Kiribati </option>
<option value="KN"> Korea North </option>
<option value="KS"> Korea South </option>
<option value="KU"> Kuwait </option>
<option value="KG"> Kyrgyzstan </option>
<option value="LA"> Laos </option>
<option value="LG"> Latvia </option>
<option value="LE"> Lebanon </option>
<option value="LT"> Lesotho </option>
<option value="LI"> Liberia </option>
<option value="LY"> Libya </option>
<option value="LS"> Liechtenstein </option>
<option value="LH"> Lithuania </option>
<option value="LU"> Luxembourg </option>
<option value="MC"> Macau </option>
<option value="MK"> Macedonia </option>
<option value="MA"> Madagascar </option>
<option value="MI"> Malawi </option>
<option value="MY"> Malaysia </option>
<option value="MV"> Maldives </option>
<option value="ML"> Mali </option>
<option value="MT"> Malta </option>
<option value="RM"> Marshall Islands </option>
<option value="MR"> Mauritania </option>
<option value="MP"> Mauritius </option>
<option value="MF"> Mayotte </option>
<option value="MX"> Mexico </option>
<option value="FM"> Micronesia Federated States Of </option>
<option value="MQ"> Midway Islands </option>
<option value="MD"> Moldova </option>
<option value="MN"> Monaco </option>
<option value="MG"> Mongolia </option>
<option value="MJ"> Montenegro </option>
<option value="MH"> Montserrat </option>
<option value="MO"> Morocco </option>
<option value="MZ"> Mozambique </option>
<option value="WA"> Namibia </option>
<option value="NR"> Nauru </option>
<option value="BQ"> Navassa Island </option>
<option value="NP"> Nepal </option>
<option value="NL"> Netherlands </option>
<option value="NT"> Netherlands Antilles </option>
<option value="NC"> New Caledonia </option>
<option value="NZ"> New Zealand </option>
<option value="NU"> Nicaragua </option>
<option value="NG"> Niger </option>
<option value="NI"> Nigeria </option>
<option value="NE"> Niue </option>
<option value="NF"> Norfolk Island </option>
<option value="CQ"> Northern Mariana Islands </option>
<option value="NO"> Norway </option>
<option value="MU"> Oman </option>
<option value="PK"> Pakistan </option>
<option value="PS"> Palau </option>
<option value="LQ"> Palmyra Atoll </option>
<option value="PM"> Panama </option>
<option value="PP"> Papua New Guinea </option>
<option value="PF"> Paracel Islands </option>
<option value="PA"> Paraguay </option>
<option value="PE"> Peru </option>
<option value="RP"> Philippines </option>
<option value="PC"> Pitcairn Islands </option>
<option value="PL"> Poland </option>
<option value="PO"> Portugal </option>
<option value="QA"> Qatar </option>
<option value="RO"> Romania </option>
<option value="RS"> Russia </option>
<option value="RW"> Rwanda </option>
<option value="SH"> Saint Helena </option>
<option value="SC"> Saint Kitts And Nevis </option>
<option value="ST"> Saint Lucia </option>
<option value="SB"> Saint Pierre And Miquelon </option>
<option value="VC"> Saint Vincent And Grenadines </option>
<option value="WS"> Samoa </option>
<option value="SM"> San Marino </option>
<option value="TP"> Sao Tome And Principe </option>
<option value="SA"> Saudi Arabia </option>
<option value="SG"> Senegal </option>
<option value="RB"> Serbia </option>
<option value="SE"> Seychelles </option>
<option value="SL"> Sierra Leone </option>
<option value="SN"> Singapore </option>
<option value="LO"> Slovakia </option>
<option value="SI"> Slovenia </option>
<option value="BP"> Solomon Islands </option>
<option value="SO"> Somalia </option>
<option value="SF"> South Africa </option>
<option value="SX"> South Georgia And South Sandwich Islands </option>
<option value="SP"> Spain </option>
<option value="PG"> Spratly Islands </option>
<option value="CE"> Sri Lanka </option>
<option value="SU"> Sudan </option>
<option value="NS"> Suriname </option>
<option value="SV"> Svalbard </option>
<option value="WZ"> Swaziland </option>
<option value="SW"> Sweden </option>
<option value="SZ"> Switzerland </option>
<option value="SY"> Syria </option>
<option value="TW"> Taiwan </option>
<option value="TI"> Tajikistan </option>
<option value="TZ"> Tanzania </option>
<option value="TH"> Thailand </option>
<option value="TO"> Togo </option>
<option value="TL"> Tokelau </option>
<option value="TN"> Tonga </option>
<option value="TD"> Trinidad And Tobago </option>
<option value="TS"> Tunisia </option>
<option value="TU"> Turkey </option>
<option value="TX"> Turkmenistan </option>
<option value="TK"> Turks And Caicos Islands </option>
<option value="TV"> Tuvalu </option>
<option value="UG"> Uganda </option>
<option value="UP"> Ukraine </option>
<option value="AE"> United Arab Emirates </option>
<option value="UK"> United Kingdom </option>
<option value="UY"> Uruguay </option>
<option value="UZ"> Uzbekistan </option>
<option value="NH"> Vanuatu </option>
<option value="VE"> Venezuela </option>
<option value="VM"> Vietnam </option>
<option value="VI"> Virgin Islands British </option>
<option value="WQ"> Wake Island </option>
<option value="WF"> Wallis And Futuna </option>
<option value="WI"> Western Sahara </option>
<option value="YM"> Yemen </option>
<option value="ZA"> Zambia </option>
<option value="ZI"> Zimbabwe </option>
</select>
</div>
</div>
<div class="form-group row mailing-state-field" style="display: none;">
<label for="s2_state" class="col-sm-4 col-form-label">State</label>
<div class="col-sm-8">
<select class="form-control" id="s2_state" name="mailing_state">
<option value="" disabled="" selected="">Select state</option>
<option value="AL"> Alabama </option>
<option value="AK"> Alaska </option>
<option value="AZ"> Arizona </option>
<option value="AR"> Arkansas </option>
<option value="CA"> California </option>
<option value="CO"> Colorado </option>
<option value="CT"> Connecticut </option>
<option value="DE"> Delaware </option>
<option value="DC"> District Of Columbia </option>
<option value="FL"> Florida </option>
<option value="GA"> Georgia </option>
<option value="HI"> Hawaii </option>
<option value="ID"> Idaho </option>
<option value="IL"> Illinois </option>
<option value="IN"> Indiana </option>
<option value="IA"> Iowa </option>
<option value="KS"> Kansas </option>
<option value="KY"> Kentucky </option>
<option value="LA"> Louisiana </option>
<option value="ME"> Maine </option>
<option value="MD"> Maryland </option>
<option value="MA"> Massachusetts </option>
<option value="MI"> Michigan </option>
<option value="MN"> Minnesota </option>
<option value="MS"> Mississippi </option>
<option value="MO"> Missouri </option>
<option value="MT"> Montana </option>
<option value="NE"> Nebraska </option>
<option value="NV"> Nevada </option>
<option value="NH"> New Hampshire </option>
<option value="NJ"> New Jersey </option>
<option value="NM"> New Mexico </option>
<option value="NY"> New York </option>
<option value="NC"> North Carolina </option>
<option value="ND"> North Dakota </option>
<option value="OH"> Ohio </option>
<option value="OK"> Oklahoma </option>
<option value="OR"> Oregon </option>
<option value="PA"> Pennsylvania </option>
<option value="RI"> Rhode Island </option>
<option value="SC"> South Carolina </option>
<option value="SD"> South Dakota </option>
<option value="TN"> Tennessee </option>
<option value="TX"> Texas </option>
<option value="UT"> Utah </option>
<option value="VT"> Vermont </option>
<option value="VA"> Virginia </option>
<option value="WA"> Washington </option>
<option value="WV"> West Virginia </option>
<option value="WI"> Wisconsin </option>
<option value="WY"> Wyoming </option>
<option value="AS"> American Samoa </option>
<option value="FM"> Federated States Of Micronesia </option>
<option value="GU"> Guam </option>
<option value="MH"> Marshall Islands </option>
<option value="MP"> Northern Mariana Islands </option>
<option value="PW"> Palau </option>
<option value="PR"> Puerto Rico </option>
<option value="VI"> Virgin Islands </option>
<option value="AE"> Armed Forces Middle East </option>
<option value="AA"> Armed Forces Americas </option>
<option value="AP"> Armed Forces Pacific </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="s2_zip_code" class="col-sm-4 col-form-label">Zip Code</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_zip_code" name="mailing_zip" value="" required="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Is this your Permanent Address?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="permanent_address_same" id="permanent-yes" value="1" required="">
<label class="form-check-label" for="permanent-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="permanent_address_same" id="permanent-no" value="0" required="">
<label class="form-check-label" for="permanent-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="permanent-address-fields" style="display: none;">
<div class="form-group row">
<label for="s2_pstreet_address1" class="col-sm-4 col-form-label">Street Address/RFD#, PO Box, or URB</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s2_pstreet_address1" name="permanent_address_1" value="">
</div>
</div>
<div class="form-group row">
<label for="s2_pstreet_address2" class="col-sm-4 col-form-label">Street Address 2 (Include Apartment, Suite, etc)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_pstreet_address2" name="permanent_address_2" value="">
</div>
</div>
<div class="form-group row">
<label for="s2_pcity_birth" class="col-sm-4 col-form-label">City</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s2_pcity_birth" name="permanent_city" value="">
</div>
</div>
<div class="form-group row">
<label for="s2_pcountry_birth" class="col-sm-4 col-form-label">Country</label>
<div class="col-sm-8">
<select class="form-control required" id="s2_pcountry_birth" name="permanent_country">
<option value="" disabled="" selected="">Select country</option>
<option value="US"> United States </option>
<option value="AF"> Afghanistan </option>
<option value="AX"> Akrotiri Sovereign Base Area </option>
<option value="AL"> Albania </option>
<option value="AG"> Algeria </option>
<option value="AN"> Andorra </option>
<option value="AO"> Angola </option>
<option value="AV"> Anguilla </option>
<option value="AY"> Antarctica </option>
<option value="AC"> Antigua And Barbuda </option>
<option value="AR"> Argentina </option>
<option value="AM"> Armenia </option>
<option value="AA"> Aruba </option>
<option value="AT"> Ashmore And Cartier Islands </option>
<option value="AS"> Australia </option>
<option value="AU"> Austria </option>
<option value="AJ"> Azerbaijan </option>
<option value="BF"> Bahamas </option>
<option value="BA"> Bahrain </option>
<option value="FQ"> Baker Island </option>
<option value="BG"> Bangladesh </option>
<option value="BB"> Barbados </option>
<option value="BO"> Belarus </option>
<option value="BE"> Belgium </option>
<option value="BH"> Belize </option>
<option value="BN"> Benin </option>
<option value="BD"> Bermuda </option>
<option value="BT"> Bhutan </option>
<option value="BL"> Bolivia </option>
<option value="BK"> Bosnia And Herzegovina </option>
<option value="BC"> Botswana </option>
<option value="BV"> Bouvet Island </option>
<option value="BR"> Brazil </option>
<option value="IO"> British Indian Ocean Territory </option>
<option value="BX"> Brunei </option>
<option value="BU"> Bulgaria </option>
<option value="UV"> Burkina Faso </option>
<option value="BM"> Burma </option>
<option value="BY"> Burundi </option>
<option value="CB"> Cambodia </option>
<option value="CM"> Cameroon </option>
<option value="CA"> Canada </option>
<option value="CV"> Cape Verde </option>
<option value="CJ"> Cayman Islands </option>
<option value="CT"> Central African Republic </option>
<option value="CD"> Chad </option>
<option value="CI"> Chile </option>
<option value="CH"> China </option>
<option value="KT"> Christmas Island </option>
<option value="IP"> Clipperton Island </option>
<option value="CK"> Cocos Keeling Islands </option>
<option value="CO"> Colombia </option>
<option value="CN"> Comoros </option>
<option value="CF"> Congo Brazzaville </option>
<option value="CG"> Congo Kinshasa </option>
<option value="CW"> Cook Islands </option>
<option value="CR"> Coral Sea Islands </option>
<option value="CS"> Costa Rica </option>
<option value="IV"> Cote D Ivoire </option>
<option value="HR"> Croatia </option>
<option value="CU"> Cuba </option>
<option value="CY"> Cyprus </option>
<option value="EZ"> Czech Republic </option>
<option value="DA"> Denmark </option>
<option value="DX"> Dhekelia Sovereign Base Area </option>
<option value="DJ"> Djibouti </option>
<option value="DO"> Dominica </option>
<option value="DR"> Dominican Republic </option>
<option value="TT"> East Timor </option>
<option value="EC"> Ecuador </option>
<option value="EG"> Egypt </option>
<option value="ES"> El Salvador </option>
<option value="EK"> Equatorial Guinea </option>
<option value="ER"> Eritrea </option>
<option value="EN"> Estonia </option>
<option value="ET"> Ethiopia </option>
<option value="FK"> Falkland Islands Islas Malvinas </option>
<option value="FO"> Faroe Islands </option>
<option value="FJ"> Fiji </option>
<option value="FI"> Finland </option>
<option value="FR"> France </option>
<option value="FP"> French Polynesia </option>
<option value="FS"> French Southern And Antarctic Lands </option>
<option value="GB"> Gabon </option>
<option value="GA"> Gambia </option>
<option value="GG"> Georgia </option>
<option value="GM"> Germany </option>
<option value="GH"> Ghana </option>
<option value="GI"> Gibraltar </option>
<option value="GR"> Greece </option>
<option value="GL"> Greenland </option>
<option value="GJ"> Grenada </option>
<option value="GT"> Guatemala </option>
<option value="GK"> Guernsey </option>
<option value="GV"> Guinea </option>
<option value="PU"> Guinea Bissau </option>
<option value="GY"> Guyana </option>
<option value="HA"> Haiti </option>
<option value="HM"> Heard Island And Mcdonald Islands </option>
<option value="VT"> Holy See </option>
<option value="HO"> Honduras </option>
<option value="HK"> Hong Kong </option>
<option value="HQ"> Howland Island </option>
<option value="HU"> Hungary </option>
<option value="IC"> Iceland </option>
<option value="IN"> India </option>
<option value="ID"> Indonesia </option>
<option value="IR"> Iran </option>
<option value="IZ"> Iraq </option>
<option value="EI"> Ireland </option>
<option value="IM"> Isle Of Man </option>
<option value="IS"> Israel </option>
<option value="IT"> Italy </option>
<option value="JM"> Jamaica </option>
<option value="JN"> Jan Mayen </option>
<option value="JA"> Japan </option>
<option value="DQ"> Jarvis Island </option>
<option value="JE"> Jersey </option>
<option value="JQ"> Johnston Atoll </option>
<option value="JO"> Jordan </option>
<option value="KZ"> Kazakhstan </option>
<option value="KE"> Kenya </option>
<option value="KQ"> Kingman Reef </option>
<option value="KR"> Kiribati </option>
<option value="KN"> Korea North </option>
<option value="KS"> Korea South </option>
<option value="KU"> Kuwait </option>
<option value="KG"> Kyrgyzstan </option>
<option value="LA"> Laos </option>
<option value="LG"> Latvia </option>
<option value="LE"> Lebanon </option>
<option value="LT"> Lesotho </option>
<option value="LI"> Liberia </option>
<option value="LY"> Libya </option>
<option value="LS"> Liechtenstein </option>
<option value="LH"> Lithuania </option>
<option value="LU"> Luxembourg </option>
<option value="MC"> Macau </option>
<option value="MK"> Macedonia </option>
<option value="MA"> Madagascar </option>
<option value="MI"> Malawi </option>
<option value="MY"> Malaysia </option>
<option value="MV"> Maldives </option>
<option value="ML"> Mali </option>
<option value="MT"> Malta </option>
<option value="RM"> Marshall Islands </option>
<option value="MR"> Mauritania </option>
<option value="MP"> Mauritius </option>
<option value="MF"> Mayotte </option>
<option value="MX"> Mexico </option>
<option value="FM"> Micronesia Federated States Of </option>
<option value="MQ"> Midway Islands </option>
<option value="MD"> Moldova </option>
<option value="MN"> Monaco </option>
<option value="MG"> Mongolia </option>
<option value="MJ"> Montenegro </option>
<option value="MH"> Montserrat </option>
<option value="MO"> Morocco </option>
<option value="MZ"> Mozambique </option>
<option value="WA"> Namibia </option>
<option value="NR"> Nauru </option>
<option value="BQ"> Navassa Island </option>
<option value="NP"> Nepal </option>
<option value="NL"> Netherlands </option>
<option value="NT"> Netherlands Antilles </option>
<option value="NC"> New Caledonia </option>
<option value="NZ"> New Zealand </option>
<option value="NU"> Nicaragua </option>
<option value="NG"> Niger </option>
<option value="NI"> Nigeria </option>
<option value="NE"> Niue </option>
<option value="NF"> Norfolk Island </option>
<option value="CQ"> Northern Mariana Islands </option>
<option value="NO"> Norway </option>
<option value="MU"> Oman </option>
<option value="PK"> Pakistan </option>
<option value="PS"> Palau </option>
<option value="LQ"> Palmyra Atoll </option>
<option value="PM"> Panama </option>
<option value="PP"> Papua New Guinea </option>
<option value="PF"> Paracel Islands </option>
<option value="PA"> Paraguay </option>
<option value="PE"> Peru </option>
<option value="RP"> Philippines </option>
<option value="PC"> Pitcairn Islands </option>
<option value="PL"> Poland </option>
<option value="PO"> Portugal </option>
<option value="QA"> Qatar </option>
<option value="RO"> Romania </option>
<option value="RS"> Russia </option>
<option value="RW"> Rwanda </option>
<option value="SH"> Saint Helena </option>
<option value="SC"> Saint Kitts And Nevis </option>
<option value="ST"> Saint Lucia </option>
<option value="SB"> Saint Pierre And Miquelon </option>
<option value="VC"> Saint Vincent And Grenadines </option>
<option value="WS"> Samoa </option>
<option value="SM"> San Marino </option>
<option value="TP"> Sao Tome And Principe </option>
<option value="SA"> Saudi Arabia </option>
<option value="SG"> Senegal </option>
<option value="RB"> Serbia </option>
<option value="SE"> Seychelles </option>
<option value="SL"> Sierra Leone </option>
<option value="SN"> Singapore </option>
<option value="LO"> Slovakia </option>
<option value="SI"> Slovenia </option>
<option value="BP"> Solomon Islands </option>
<option value="SO"> Somalia </option>
<option value="SF"> South Africa </option>
<option value="SX"> South Georgia And South Sandwich Islands </option>
<option value="SP"> Spain </option>
<option value="PG"> Spratly Islands </option>
<option value="CE"> Sri Lanka </option>
<option value="SU"> Sudan </option>
<option value="NS"> Suriname </option>
<option value="SV"> Svalbard </option>
<option value="WZ"> Swaziland </option>
<option value="SW"> Sweden </option>
<option value="SZ"> Switzerland </option>
<option value="SY"> Syria </option>
<option value="TW"> Taiwan </option>
<option value="TI"> Tajikistan </option>
<option value="TZ"> Tanzania </option>
<option value="TH"> Thailand </option>
<option value="TO"> Togo </option>
<option value="TL"> Tokelau </option>
<option value="TN"> Tonga </option>
<option value="TD"> Trinidad And Tobago </option>
<option value="TS"> Tunisia </option>
<option value="TU"> Turkey </option>
<option value="TX"> Turkmenistan </option>
<option value="TK"> Turks And Caicos Islands </option>
<option value="TV"> Tuvalu </option>
<option value="UG"> Uganda </option>
<option value="UP"> Ukraine </option>
<option value="AE"> United Arab Emirates </option>
<option value="UK"> United Kingdom </option>
<option value="UY"> Uruguay </option>
<option value="UZ"> Uzbekistan </option>
<option value="NH"> Vanuatu </option>
<option value="VE"> Venezuela </option>
<option value="VM"> Vietnam </option>
<option value="VI"> Virgin Islands British </option>
<option value="WQ"> Wake Island </option>
<option value="WF"> Wallis And Futuna </option>
<option value="WI"> Western Sahara </option>
<option value="YM"> Yemen </option>
<option value="ZA"> Zambia </option>
<option value="ZI"> Zimbabwe </option>
</select>
</div>
</div>
<div class="form-group row permanent-state-field" style="display: none;">
<label for="s2_pstate_birth" class="col-sm-4 col-form-label">State</label>
<div class="col-sm-8">
<select class="form-control" id="s2_pstate_birth" name="permanent_state">
<option value="" disabled="" selected="">Select state</option>
<option value="AL"> Alabama </option>
<option value="AK"> Alaska </option>
<option value="AZ"> Arizona </option>
<option value="AR"> Arkansas </option>
<option value="CA"> California </option>
<option value="CO"> Colorado </option>
<option value="CT"> Connecticut </option>
<option value="DE"> Delaware </option>
<option value="DC"> District Of Columbia </option>
<option value="FL"> Florida </option>
<option value="GA"> Georgia </option>
<option value="HI"> Hawaii </option>
<option value="ID"> Idaho </option>
<option value="IL"> Illinois </option>
<option value="IN"> Indiana </option>
<option value="IA"> Iowa </option>
<option value="KS"> Kansas </option>
<option value="KY"> Kentucky </option>
<option value="LA"> Louisiana </option>
<option value="ME"> Maine </option>
<option value="MD"> Maryland </option>
<option value="MA"> Massachusetts </option>
<option value="MI"> Michigan </option>
<option value="MN"> Minnesota </option>
<option value="MS"> Mississippi </option>
<option value="MO"> Missouri </option>
<option value="MT"> Montana </option>
<option value="NE"> Nebraska </option>
<option value="NV"> Nevada </option>
<option value="NH"> New Hampshire </option>
<option value="NJ"> New Jersey </option>
<option value="NM"> New Mexico </option>
<option value="NY"> New York </option>
<option value="NC"> North Carolina </option>
<option value="ND"> North Dakota </option>
<option value="OH"> Ohio </option>
<option value="OK"> Oklahoma </option>
<option value="OR"> Oregon </option>
<option value="PA"> Pennsylvania </option>
<option value="RI"> Rhode Island </option>
<option value="SC"> South Carolina </option>
<option value="SD"> South Dakota </option>
<option value="TN"> Tennessee </option>
<option value="TX"> Texas </option>
<option value="UT"> Utah </option>
<option value="VT"> Vermont </option>
<option value="VA"> Virginia </option>
<option value="WA"> Washington </option>
<option value="WV"> West Virginia </option>
<option value="WI"> Wisconsin </option>
<option value="WY"> Wyoming </option>
<option value="AS"> American Samoa </option>
<option value="FM"> Federated States Of Micronesia </option>
<option value="GU"> Guam </option>
<option value="MH"> Marshall Islands </option>
<option value="MP"> Northern Mariana Islands </option>
<option value="PW"> Palau </option>
<option value="PR"> Puerto Rico </option>
<option value="VI"> Virgin Islands </option>
<option value="AE"> Armed Forces Middle East </option>
<option value="AA"> Armed Forces Americas </option>
<option value="AP"> Armed Forces Pacific </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="s2_pzip_code" class="col-sm-4 col-form-label">Zip Code</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s2_pzip_code" name="permanent_zip" value="">
</div>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Preferred Method of Communication</h5>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Preferred Method of Communication</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="method_of_communication" id="method-mail" value="1" required="">
<label class="form-check-label" for="method-mail"> Mail </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="method_of_communication" id="method-email" value="2" required="">
<label class="form-check-label" for="method-email"> Email </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="method_of_communication" id="method-both" value="3" required="">
<label class="form-check-label" for="method-both"> Both </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row">
<label for="email" class="col-sm-4 col-form-label">Email</label>
<div class="col-sm-8">
<input type="email" class="form-control" id="email" name="email" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="email-confirmation" class="col-sm-4 col-form-label">Re-enter Email</label>
<div class="col-sm-8">
<input type="email" class="form-control" id="email-confirmation" name="email_confirmation" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="phone-number" class="col-sm-4 col-form-label">Phone Number</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="phone-number" name="phone_number" placeholder="XXX-XXX-XXXX" value="" required="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Phone type</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="phone_type" id="phone_work" value="1" required="">
<label class="form-check-label" for="phone_work"> Work </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="phone_type" id="phone_home" value="2" required="">
<label class="form-check-label" for="phone_home"> Home </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="phone_type" id="phone_mobile" value="3" required="">
<label class="form-check-label" for="phone_mobile"> Mobile </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Do you want to add additional phone numbers?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="add_additional_phone_numbers" id="add-additional-phone-numbers-no" value="0">
<label class="form-check-label" for="add-additional-phone-numbers-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="add_additional_phone_numbers" id="add-additional-phone-numbers-yes" value="1">
<label class="form-check-label" for="add-additional-phone-numbers-yes"> Yes </label>
</div>
</div>
</div>
</fieldset>
<div class="additional-phone-numbers" style="display:none;">
<div class="form-group row">
<label for="s2_another_phone_number1" class="col-sm-4 col-form-label">Additional Phone Number</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_another_phone_number1" name="additional_phone_number_1" placeholder="XXX-XXX-XXXX" value="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Phone type</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_1" id="additional_phone_type_1_work" value="1">
<label class="form-check-label" for="additional_phone_type_1_work"> Work </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_1" id="additional_phone_type_1_home" value="2">
<label class="form-check-label" for="additional_phone_type_1_home"> Home </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_1" id="additional_phone_type_1_mobile" value="3">
<label class="form-check-label" for="additional_phone_type_1_mobile"> Mobile </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row">
<label for="s2_another_phone_number2" class="col-sm-4 col-form-label">Additional Phone Number</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s2_another_phone_number2" name="additional_phone_number_2" placeholder="XXX-XXX-XXXX" value="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Phone type</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_2" id="additional_phone_type_2_work" value="1">
<label class="form-check-label" for="additional_phone_type_2_work"> Work </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_2" id="additional_phone_type_2_home" value="2">
<label class="form-check-label" for="additional_phone_type_2_home"> Home </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="additional_phone_type_2" id="additional_phone_type_2_mobile" value="3">
<label class="form-check-label" for="additional_phone_type_2_mobile"> Mobile </label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Travel Plans (Optional)</h5>
<p class="mb-0 text-muted">Complete this section only if you have known travel plans. If you do not have any travel plans yet, you can skip this section.</p>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Do you have any travel plans yet?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="travel_plans" id="travel-plans-yes" value="1">
<label class="form-check-label" for="travel-plans-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="travel_plans" id="travel-plans-no" value="0" checked=""checked"">
<label class="form-check-label" for="travel-plans-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="travel-plans-fields" style="display: none;">
<div class="form-group row">
<label for="dob_trip_year" class="col-sm-4 col-form-label">Date Of Your Trip</label>
<div class="col-sm-3 mb-1">
<select class="form-control required" id="dob_trip_year" name="trip_abroad_year">
<option value="" disabled="" selected="">Year</option>
<option value="2026"> 2026 </option>
<option value="2025"> 2025 </option>
<option value="2024"> 2024 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="dob_trip_month" name="trip_abroad_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="dob_trip_day" name="trip_abroad_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="dob_return_year" class="col-sm-4 col-form-label">Date Of Your Return</label>
<div class="col-sm-3 mb-1">
<select class="form-control required" id="dob_return_year" name="trip_return_year">
<option value="" disabled="" selected="">Year</option>
<option value="2026"> 2026 </option>
<option value="2025"> 2025 </option>
<option value="2024"> 2024 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="dob_return_month" name="trip_return_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="dob_return_day" name="trip_return_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="visiting_countries" class="col-sm-4 col-form-label">Countries To Be Visited?</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="visiting_countries" name="trip_abroad_countries" value="">
</div>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Emergency Contact (Optional)</h5>
<p class="mb-0 text-muted">Complete this section only if you have an emergency contact. If you do not have one, you can skip this section.</p>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Do you have an emergency contact that you would like to add to this application?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="emergency_contact" id="emergency-contact-yes" value="1">
<label class="form-check-label" for="emergency-contact-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="emergency_contact" id="emergency-contact-no" value="0" checked=""checked"">
<label class="form-check-label" for="emergency-contact-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="emergency-contact-fields" style="display: none;">
<div class="form-group row">
<label for="emergency-contact-name" class="col-sm-4 col-form-label">Name of Emergency Contact</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="emergency-contact-name" name="emergency_contact_name" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_street_address1" class="col-sm-4 col-form-label">Street Address/RFD#, PO Box, or URB</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s4_street_address1" name="emergency_contact_address_1" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_street_address2" class="col-sm-4 col-form-label">Street Address 2 (Include Apartment, Suite, etc)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s4_street_address2" name="emergency_contact_address_2" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_city_birth" class="col-sm-4 col-form-label">City</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s4_city_birth" name="emergency_contact_city" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_state_birth" class="col-sm-4 col-form-label">State</label>
<div class="col-sm-8">
<select class="form-control required" id="s4_state_birth" name="emergency_contact_state">
<option value="" disabled="" selected="">Select state</option>
<option value="AL"> Alabama </option>
<option value="AK"> Alaska </option>
<option value="AZ"> Arizona </option>
<option value="AR"> Arkansas </option>
<option value="CA"> California </option>
<option value="CO"> Colorado </option>
<option value="CT"> Connecticut </option>
<option value="DE"> Delaware </option>
<option value="DC"> District Of Columbia </option>
<option value="FL"> Florida </option>
<option value="GA"> Georgia </option>
<option value="HI"> Hawaii </option>
<option value="ID"> Idaho </option>
<option value="IL"> Illinois </option>
<option value="IN"> Indiana </option>
<option value="IA"> Iowa </option>
<option value="KS"> Kansas </option>
<option value="KY"> Kentucky </option>
<option value="LA"> Louisiana </option>
<option value="ME"> Maine </option>
<option value="MD"> Maryland </option>
<option value="MA"> Massachusetts </option>
<option value="MI"> Michigan </option>
<option value="MN"> Minnesota </option>
<option value="MS"> Mississippi </option>
<option value="MO"> Missouri </option>
<option value="MT"> Montana </option>
<option value="NE"> Nebraska </option>
<option value="NV"> Nevada </option>
<option value="NH"> New Hampshire </option>
<option value="NJ"> New Jersey </option>
<option value="NM"> New Mexico </option>
<option value="NY"> New York </option>
<option value="NC"> North Carolina </option>
<option value="ND"> North Dakota </option>
<option value="OH"> Ohio </option>
<option value="OK"> Oklahoma </option>
<option value="OR"> Oregon </option>
<option value="PA"> Pennsylvania </option>
<option value="RI"> Rhode Island </option>
<option value="SC"> South Carolina </option>
<option value="SD"> South Dakota </option>
<option value="TN"> Tennessee </option>
<option value="TX"> Texas </option>
<option value="UT"> Utah </option>
<option value="VT"> Vermont </option>
<option value="VA"> Virginia </option>
<option value="WA"> Washington </option>
<option value="WV"> West Virginia </option>
<option value="WI"> Wisconsin </option>
<option value="WY"> Wyoming </option>
<option value="AS"> American Samoa </option>
<option value="FM"> Federated States Of Micronesia </option>
<option value="GU"> Guam </option>
<option value="MH"> Marshall Islands </option>
<option value="MP"> Northern Mariana Islands </option>
<option value="PW"> Palau </option>
<option value="PR"> Puerto Rico </option>
<option value="VI"> Virgin Islands </option>
<option value="AE"> Armed Forces Middle East </option>
<option value="AA"> Armed Forces Americas </option>
<option value="AP"> Armed Forces Pacific </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="s4_zip_code" class="col-sm-4 col-form-label">Zip Code</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s4_zip_code" name="emergency_contact_zip" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_phone" class="col-sm-4 col-form-label">Telephone Number</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s4_phone" name="emergency_contact_phone_number" value="">
</div>
</div>
<div class="form-group row">
<label for="s4_relationship" class="col-sm-4 col-form-label">Relationship to Applicant</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s4_relationship" name="emergency_contact_relationship" value="">
</div>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Your Most Recent Passport</h5>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Have you been issued any of the following?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="issued_document" id="issued-book" value="1" required="">
<label class="form-check-label" for="issued-book"> Passport Book </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="issued_document" id="issued-card" value="2" required="">
<label class="form-check-label" for="issued-card"> Passport Card </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="issued_document" id="issued-both" value="3" required="">
<label class="form-check-label" for="issued-both"> Both </label>
</div>
<div class="form-check-inline recent-passport-none" style="">
<input class="form-check-input" type="radio" name="issued_document" id="issued-none" value="0" required="">
<label class="form-check-label" for="issued-none"> None </label>
</div>
</div>
</div>
</fieldset>
<div class="passport-book" style="display: none;">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Do you still have the book in your possession?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_book" id="status-book-yes" value="1">
<label class="form-check-label" for="status-book-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_book" id="status-book-damaged" value="5">
<label class="form-check-label" for="status-book-damaged"> Yes, but it was Damaged or Mutilated </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_book" id="status-book-lost" value="4">
<label class="form-check-label" for="status-book-lost"> No, it was lost </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_book" id="status-book-stolen" value="3">
<label class="form-check-label" for="status-book-stolen"> No, it has been stolen </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group reported-stolen-book" style="display: none;">
<div class="row">
<legend class="col-sm-4 col-form-label">Is your lost or stolen passport book expired?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="book_stolen_expired" id="book-stolen-expired-yes" value="1">
<label class="form-check-label" for="book-stolen-expired-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="book_stolen_expired" id="book-stolen-expired-no" value="0">
<label class="form-check-label" for="book-stolen-expired-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="book_stolen_expired" id="book-stolen-expired-unknown" value="0">
<label class="form-check-label" for="book-stolen-expired-unknown"> Unknown </label>
</div>
</div>
</div>
<div class="row">
<legend class="col-sm-4 col-form-label">Have you reported your passport book lost or stolen book?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="book_stolen" id="book-stolen-yes" value="1">
<label class="form-check-label" for="book-stolen-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="book_stolen" id="book-stolen-no" value="0">
<label class="form-check-label" for="book-stolen-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row">
<label for="dob_return_year" class="col-sm-4 col-form-label"> The date your most recent passport book was issued <span class="text-muted show-ls" style="display: none;">(If Known)</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_year" name="recent_book_issued_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_month" name="recent_book_issued_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_day" name="recent_book_issued_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-12 col-form-label">Your name as printed on your most recent book:</label>
</div>
<div class="form-group row">
<label for="s5_first_middle_name" class="col-sm-4 col-form-label">First and Middle Name</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5_first_middle_name" name="recent_book_printed_name" value="">
</div>
</div>
<div class="form-group row">
<label for="s5_first_last_name" class="col-sm-4 col-form-label">Last Name</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5_first_last_name" name="recent_book_printed_last_name" value="">
</div>
</div>
<div class="form-group row">
<label for="s5_bookno" class="col-sm-4 col-form-label"> Book Number <span class="text-muted show-ls" style="display: none;">(If Known)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control required not-required-ls" id="s5_bookno" name="recent_book_number" value="">
</div>
</div>
</div>
<div class="passport-card" style="display: none;">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Do you still have the card in your possession?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_card" id="status-card-yes" value="1">
<label class="form-check-label" for="status-card-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_card" id="status-card-damaged" value="5">
<label class="form-check-label" for="status-card-damaged"> Yes, but it was Damaged or Mutilated </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_card" id="status-card-lost" value="4">
<label class="form-check-label" for="status-card-lost"> No, it was lost </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="status_of_most_recent_card" id="status-card-stolen" value="3">
<label class="form-check-label" for="status-card-stolen"> No, it has been stolen </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group reported-stolen-card" style="display: none;">
<div class="row">
<legend class="col-sm-4 col-form-label">Is your lost or stolen passport card expired?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="card_stolen_expired" id="card-stolen-expired-yes" value="1">
<label class="form-check-label" for="card-stolen-expired-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="card_stolen_expired" id="card-stolen-expired-no" value="0">
<label class="form-check-label" for="card-stolen-expired-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sb" type="radio" name="card_stolen_expired" id="card-stolen-expired-unknown" value="0">
<label class="form-check-label" for="card-stolen-expired-unknown"> Unknown </label>
</div>
</div>
</div>
<div class="row">
<legend class="col-sm-4 col-form-label">Have you reported your passport card lost or stolen card?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required-sc" type="radio" name="card_stolen" id="card-stolen-yes" value="1">
<label class="form-check-label" for="card-stolen-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required-sc" type="radio" name="card_stolen" id="card-stolen-no" value="0">
<label class="form-check-label" for="card-stolen-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row">
<label for="dob_return_year" class="col-sm-4 col-form-label"> The date your most recent passport card was issued <span class="text-muted show-ls" style="display: none;">(If Known)</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_cyear" name="recent_card_issued_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_cmonth" name="recent_card_issued_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required not-required-ls" id="recent_passport_cday" name="recent_card_issued_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label class="col-sm-12 col-form-label">Your name as printed on your most recent card:</label>
</div>
<div class="form-group row">
<label for="s5c_first_middle_name" class="col-sm-4 col-form-label">First and Middle Name</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_first_middle_name" name="recent_card_name" value="">
</div>
</div>
<div class="form-group row">
<label for="s5c_first_last_name" class="col-sm-4 col-form-label">Last Name</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_first_last_name" name="recent_card_last_name" value="">
</div>
</div>
<div class="form-group row">
<label for="cardno" class="col-sm-4 col-form-label"> Card Number <span class="text-muted show-ls" style="display: none;">(If Known)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control required not-required-ls" id="cardno" name="recent_card_number" value="">
</div>
</div>
</div>
<div class="row file-police-report" style="display: none;">
<legend class="col-sm-4 col-form-label">Did you file a police report for your lost or stolen passport book or card?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="filed_police_report" id="filed-police-report-no" value="0" checked=""checked"">
<label class="form-check-label" for="filed-police-report-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="filed_police_report" id="filed-police-report-yes" value="1">
<label class="form-check-label" for="filed-police-report-yes"> Yes </label>
</div>
</div>
</div>
<fieldset class="form-group lost-stolen-fields" style="display: none;">
<div class="row">
<legend class="col-sm-4 col-form-label"> Do you want to order a new U.S. passport book and/or card? <small class="d-block text-muted">If yes, we'll provide your DS-11 form for no extra cost.</small>
</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="wants_new_passport" id="wants-new-passport-no" value="0" checked=""checked"">
<label class="form-check-label" for="wants-new-passport-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="wants_new_passport" id="wants-new-passport-yes" value="1">
<label class="form-check-label" for="wants-new-passport-yes"> Yes </label>
</div>
</div>
</div>
<div class="row">
<legend class="col-sm-4 col-form-label">Has your name changed since the passport was issued?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="missing_changed_name" id="lost-stolen-changed-name-no" value="0" checked=""checked"">
<label class="form-check-label" for="lost-stolen-changed-name-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="missing_changed_name" id="lost-stolen-changed-name-yes" value="1">
<label class="form-check-label" for="lost-stolen-changed-name-yes"> Yes </label>
</div>
</div>
</div>
<div class="row missing-passport-name" style="display:none;">
<label for="name-on-missing-passport" class="col-sm-4 col-form-label">State your full name that appeared on the lost or stolen passport</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="name-on-missing-passport" name="name_on_missing_passport" value="">
</div>
</div>
<div class="missing-book" style="display:none;">
<h4 class="mt-4 mb-3">Lost or Stolen Book Information</h4>
<div class="form-group row">
<label for="missing-book-explanation" class="col-sm-4 col-form-label">Explain how the book was lost or stolen</label>
<div class="col-sm-8">
<textarea class="form-control" id="missing-book-explanation" name="missing_book_explanation"></textarea>
</div>
</div>
<div class="form-group row">
<label for="missing-book-location" class="col-sm-4 col-form-label">Where did the loss or theft occur? Provide the address if known (city/state or city/country)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="missing-book-location" name="missing_book_location" value="">
</div>
</div>
<div class="form-group row">
<label for="missing-book-year" class="col-sm-4 col-form-label"> When was the book lost or stolen? <span class="text-muted">If unknown, when was the last time you remember it being in your possession?</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="missing-book-year" name="missing_book_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-book-month" name="missing_book_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-book-day" name="missing_book_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
</div>
<div class="missing-card" style="display:none;">
<h4 class="mt-4 mb-3">Lost or Stolen Card Information</h4>
<div class="form-group row">
<label for="missing-card-explanation" class="col-sm-4 col-form-label">Explain how the card was lost or stolen</label>
<div class="col-sm-8">
<textarea class="form-control" id="missing-card-explanation" name="missing_card_explanation"></textarea>
</div>
</div>
<div class="form-group row">
<label for="missing-card-location" class="col-sm-4 col-form-label">Where did the loss or theft occur? Provide the address if known (city/state or city/country)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="missing-card-location" name="missing_card_location" value="">
</div>
</div>
<div class="form-group row">
<label for="missing-card-year" class="col-sm-4 col-form-label"> When was the card lost or stolen? <span class="text-muted">If unknown, when was the last time you remember it being in your possession?</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="missing-card-year" name="missing_card_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-card-month" name="missing_card_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-card-day" name="missing_card_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
</div>
<div class="other-missing-passports">
<h5 class="mt-4 mb-3">Other Missing Passports Information</h5>
<div class="row">
<legend class="col-sm-4 col-form-label">Have you had another U.S. passport book/card lost or stolen?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="have_had_missing_passport" id="have-had-missing-passport-no" value="0" checked=""checked"">
<label class="form-check-label" for="have-had-missing-passport-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="have_had_missing_passport" id="have-had-missing-passport-yes" value="1">
<label class="form-check-label" for="have-had-missing-passport-yes"> Yes </label>
</div>
</div>
</div>
<div class="other-missing-passports-yes" style="display:none;">
<div class="form-group row">
<label for="missing-passport-quantity" class="col-sm-4 col-form-label">How many passports?</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="missing-passport-quantity" name="missing_passport_quantity" value="">
</div>
</div>
<div class="form-group row">
<label for="missing-passport-year" class="col-sm-4 col-form-label">Approximate date?</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="missing-passport-year" name="missing_passport_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-passport-month" name="missing_passport_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="missing-passport-day" name="missing_passport_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="row">
<legend class="col-sm-4 col-form-label">Did you file a police report?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="missing_passport_filed_police_report" id="missing-passport-filed-police-report-no" value="0" checked=""checked"">
<label class="form-check-label" for="missing-passport-filed-police-report-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="missing_passport_filed_police_report" id="missing-passport-filed-police-report-yes" value="1">
<label class="form-check-label" for="missing-passport-filed-police-report-yes"> Yes </label>
</div>
</div>
</div>
</div>
</div>
</fieldset>
<div class="name-change" style="display: none;">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Has your name changed since your most recent passport was issued?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="changed_name" id="changed-name-no" value="0" checked=""checked"">
<label class="form-check-label" for="changed-name-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="changed_name" id="changed-name-yes" value="1">
<label class="form-check-label" for="changed-name-yes"> Yes </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group name-change-info" style="display:none;">
<div class="row">
<legend class="col-sm-4 col-form-label">Reason for the name change?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="name_change_reason" id="reason-name-change-marriage" value="1">
<label class="form-check-label" for="reason-name-change-marriage"> Marriage </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="name_change_reason" id="reason-name-change-court" value="2">
<label class="form-check-label" for="reason-name-change-court"> Court Order </label>
</div>
</div>
</div>
<div class="row">
<legend class="col-sm-4 col-form-label">Do you have an official document to verify your name change?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="name_change_document" id="name-change-document-no" value="0">
<label class="form-check-label" for="name-change-document-no"> No </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="name_change_document" id="name-change-document-yes" value="1">
<label class="form-check-label" for="name-change-document-yes"> Yes </label>
</div>
</div>
</div>
<div class="form-group row">
<label for="name-change-year" class="col-sm-4 col-form-label">Date of Name Change</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="name-change-year" name="name_change_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="name-change-month" name="name_change_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="name-change-day" name="name_change_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="name-change-place" class="col-sm-4 col-form-label">Place of name change (City/State)</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="name-change-place" name="name_change_place" value="">
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Applicant's Parent Information</h5>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Mother/Father/Parent Of Applicant</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="checkbox" name="parent_1_unknown" id="unknown1-yes" value="1">
<label class="form-check-label" for="unknown1-yes"> Unknown </label>
</div>
</div>
</div>
</fieldset>
<div class="unknown-parent-detail-1" style="">
<div class="form-group row">
<label for="s5c_first_name" class="col-sm-4 col-form-label">First & Middle Name (at Parent's Birth)</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_first_name" name="parent_1_name" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="s5c_last_name" class="col-sm-4 col-form-label">Last Name (at Parent's Birth)</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_last_name" name="parent_1_last_name" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="parent_dob_year" class="col-sm-4 col-form-label"> Date of birth <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="parent_dob_year" name="parent_1_year_of_birth">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="parent_dob_month" name="parent_1_month_of_birth" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="parent_dob_day" name="parent_1_day_of_birth" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="s6_pob_1" class="col-sm-4 col-form-label"> Place of Birth <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s6_pob_1" name="parent_1_place_of_birth" value="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Gender</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_1_gender" id="s6_gender1-male" value="male" required="">
<label class="form-check-label" for="s6_gender1-male"> Male </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_1_gender" id="s6_gender1-female" value="female" required="">
<label class="form-check-label" for="s6_gender1-female"> Female </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">U.S. Citizen</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_1_us_citizen" id="us_citizen1-yes" value="1" required="">
<label class="form-check-label" for="us_citizen1-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_1_us_citizen" id="us_citizen1-no" value="0" required="">
<label class="form-check-label" for="us_citizen1-no"> No </label>
</div>
</div>
</div>
</fieldset>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Mother/Father/Parent Of Applicant</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="checkbox" name="parent_2_unknown" id="unknown2-yes" value="1">
<label class="form-check-label" for="unknown2-yes"> Unknown </label>
</div>
</div>
</div>
</fieldset>
<div class="unknown-parent-detail-2" style="">
<div class="form-group row">
<label for="s5c_first_name2" class="col-sm-4 col-form-label">First & Middle Name (at Parent's Birth)</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_first_name2" name="parent_2_name" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="s5c_last_name2" class="col-sm-4 col-form-label">Last Name (at Parent's Birth)</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="s5c_last_name2" name="parent_2_last_name" value="" required="">
</div>
</div>
<div class="form-group row">
<label for="parent_dob_year2" class="col-sm-4 col-form-label"> Date of birth <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-3 mb-1">
<select class="form-control" id="parent_dob_year2" name="parent_2_year_of_birth">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="parent_dob_month2" name="parent_2_month_of_birth" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control" id="parent_dob_day2" name="parent_2_day_of_birth" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="s6_pob_2" class="col-sm-4 col-form-label"> Place of Birth <span class="text-muted">(Optional)</span>
</label>
<div class="col-sm-8">
<input type="text" class="form-control" id="s6_pob_2" name="parent_2_place_of_birth" value="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Gender</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_2_gender" id="s6_gender2-male" value="male" required="">
<label class="form-check-label" for="s6_gender2-male"> Male </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_2_gender" id="s6_gender2-female" value="female" required="">
<label class="form-check-label" for="s6_gender2-female"> Female </label>
</div>
</div>
</div>
</fieldset>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">U.S. Citizen</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_2_us_citizen" id="us_citizen2-yes" value="1" required="">
<label class="form-check-label" for="us_citizen2-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="parent_2_us_citizen" id="us_citizen2-no" value="0" required="">
<label class="form-check-label" for="us_citizen2-no"> No </label>
</div>
</div>
</div>
</fieldset>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Spouse Of Applicant</h5>
</div>
<div class="card-body">
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Has Applicant Ever Been Married?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="been_married" id="married-yes" value="1">
<label class="form-check-label" for="married-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input" type="radio" name="been_married" id="married-no" value="0">
<label class="form-check-label" for="married-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="applicant-married-fields" style="display: none;">
<div class="form-group row spouse_first_name">
<label for="spouse_first_name" class="col-sm-4 col-form-label">Applicant's Spouse's Or Former Spouse's Full Name:</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="spouse_first_name" name="spouse_full_name" value="">
</div>
</div>
<div class="form-group row">
<label for="spouse-dob-year" class="col-sm-4 col-form-label">Date of Birth</label>
<div class="col-sm-3 mb-1">
<select class="form-control required" id="spouse-dob-year" name="spouse_year_of_birth">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="spouse-dob-month" name="spouse_month_of_birth" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="spouse-dob-day" name="spouse_day_of_birth" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<div class="form-group row">
<label for="spouse-city-birth" class="col-sm-4 col-form-label">Place of Birth</label>
<div class="col-sm-8">
<input type="text" class="form-control required" id="spouse-city-birth" name="spouse_place_of_birth" value="">
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">U.S. Citizen</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="spouse_us_citizen" id="spouse-us-citizen-yes" value="1">
<label class="form-check-label" for="spouse-us-citizen-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="spouse_us_citizen" id="spouse-us-citizen-no" value="0">
<label class="form-check-label" for="spouse-us-citizen-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="form-group row">
<label for="spouse-dob-year" class="col-sm-4 col-form-label">Date Of Most Recent Marriage </label>
<div class="col-sm-3 mb-1">
<select class="form-control required" id="spouse-marriage-year" name="marriage_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="spouse-marriage-month" name="marriage_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required" id="spouse-marriage-day" name="marriage_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
<fieldset class="form-group">
<div class="row">
<legend class="col-sm-4 col-form-label">Has applicant ever been widowed or divorced?</legend>
<div class="col-sm-8">
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="widowed_or_divorced" id="widowed-yes" value="1">
<label class="form-check-label" for="widowed-yes"> Yes </label>
</div>
<div class="form-check-inline">
<input class="form-check-input required" type="radio" name="widowed_or_divorced" id="widowed-no" value="0">
<label class="form-check-label" for="widowed-no"> No </label>
</div>
</div>
</div>
</fieldset>
<div class="widow-divorce-fields" style="display: none;">
<div class="form-group row">
<label for="spouse-dob-year" class="col-sm-4 col-form-label">Date</label>
<div class="col-sm-3 mb-1">
<select class="form-control required-wd" id="spouse-widow-year" name="widow_divorce_year">
<option value="" disabled="" selected="">Year</option>
<option value="2024"> 2024 </option>
<option value="2023"> 2023 </option>
<option value="2022"> 2022 </option>
<option value="2021"> 2021 </option>
<option value="2020"> 2020 </option>
<option value="2019"> 2019 </option>
<option value="2018"> 2018 </option>
<option value="2017"> 2017 </option>
<option value="2016"> 2016 </option>
<option value="2015"> 2015 </option>
<option value="2014"> 2014 </option>
<option value="2013"> 2013 </option>
<option value="2012"> 2012 </option>
<option value="2011"> 2011 </option>
<option value="2010"> 2010 </option>
<option value="2009"> 2009 </option>
<option value="2008"> 2008 </option>
<option value="2007"> 2007 </option>
<option value="2006"> 2006 </option>
<option value="2005"> 2005 </option>
<option value="2004"> 2004 </option>
<option value="2003"> 2003 </option>
<option value="2002"> 2002 </option>
<option value="2001"> 2001 </option>
<option value="2000"> 2000 </option>
<option value="1999"> 1999 </option>
<option value="1998"> 1998 </option>
<option value="1997"> 1997 </option>
<option value="1996"> 1996 </option>
<option value="1995"> 1995 </option>
<option value="1994"> 1994 </option>
<option value="1993"> 1993 </option>
<option value="1992"> 1992 </option>
<option value="1991"> 1991 </option>
<option value="1990"> 1990 </option>
<option value="1989"> 1989 </option>
<option value="1988"> 1988 </option>
<option value="1987"> 1987 </option>
<option value="1986"> 1986 </option>
<option value="1985"> 1985 </option>
<option value="1984"> 1984 </option>
<option value="1983"> 1983 </option>
<option value="1982"> 1982 </option>
<option value="1981"> 1981 </option>
<option value="1980"> 1980 </option>
<option value="1979"> 1979 </option>
<option value="1978"> 1978 </option>
<option value="1977"> 1977 </option>
<option value="1976"> 1976 </option>
<option value="1975"> 1975 </option>
<option value="1974"> 1974 </option>
<option value="1973"> 1973 </option>
<option value="1972"> 1972 </option>
<option value="1971"> 1971 </option>
<option value="1970"> 1970 </option>
<option value="1969"> 1969 </option>
<option value="1968"> 1968 </option>
<option value="1967"> 1967 </option>
<option value="1966"> 1966 </option>
<option value="1965"> 1965 </option>
<option value="1964"> 1964 </option>
<option value="1963"> 1963 </option>
<option value="1962"> 1962 </option>
<option value="1961"> 1961 </option>
<option value="1960"> 1960 </option>
<option value="1959"> 1959 </option>
<option value="1958"> 1958 </option>
<option value="1957"> 1957 </option>
<option value="1956"> 1956 </option>
<option value="1955"> 1955 </option>
<option value="1954"> 1954 </option>
<option value="1953"> 1953 </option>
<option value="1952"> 1952 </option>
<option value="1951"> 1951 </option>
<option value="1950"> 1950 </option>
<option value="1949"> 1949 </option>
<option value="1948"> 1948 </option>
<option value="1947"> 1947 </option>
<option value="1946"> 1946 </option>
<option value="1945"> 1945 </option>
<option value="1944"> 1944 </option>
<option value="1943"> 1943 </option>
<option value="1942"> 1942 </option>
<option value="1941"> 1941 </option>
<option value="1940"> 1940 </option>
<option value="1939"> 1939 </option>
<option value="1938"> 1938 </option>
<option value="1937"> 1937 </option>
<option value="1936"> 1936 </option>
<option value="1935"> 1935 </option>
<option value="1934"> 1934 </option>
<option value="1933"> 1933 </option>
<option value="1932"> 1932 </option>
<option value="1931"> 1931 </option>
<option value="1930"> 1930 </option>
<option value="1929"> 1929 </option>
<option value="1928"> 1928 </option>
<option value="1927"> 1927 </option>
<option value="1926"> 1926 </option>
<option value="1925"> 1925 </option>
<option value="1924"> 1924 </option>
<option value="1923"> 1923 </option>
<option value="1922"> 1922 </option>
<option value="1921"> 1921 </option>
<option value="1920"> 1920 </option>
<option value="1919"> 1919 </option>
<option value="1918"> 1918 </option>
<option value="1917"> 1917 </option>
<option value="1916"> 1916 </option>
<option value="1915"> 1915 </option>
<option value="1914"> 1914 </option>
<option value="1913"> 1913 </option>
<option value="1912"> 1912 </option>
<option value="1911"> 1911 </option>
<option value="1910"> 1910 </option>
<option value="1909"> 1909 </option>
<option value="1908"> 1908 </option>
<option value="1907"> 1907 </option>
<option value="1906"> 1906 </option>
<option value="1905"> 1905 </option>
<option value="1904"> 1904 </option>
<option value="1903"> 1903 </option>
<option value="1902"> 1902 </option>
<option value="1901"> 1901 </option>
<option value="1900"> 1900 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required-wd" id="spouse-widow-month" name="widow_divorce_month" placeholder="Month">
<option value="" disabled="" selected="">Month</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
</select>
</div>
<div class="col-sm-2 mb-1">
<select class="form-control required-wd" id="spouse-widow-day" name="widow_divorce_day" placeholder="Day">
<option value="" disabled="" selected="">Day</option>
<option value="1"> 1 </option>
<option value="2"> 2 </option>
<option value="3"> 3 </option>
<option value="4"> 4 </option>
<option value="5"> 5 </option>
<option value="6"> 6 </option>
<option value="7"> 7 </option>
<option value="8"> 8 </option>
<option value="9"> 9 </option>
<option value="10"> 10 </option>
<option value="11"> 11 </option>
<option value="12"> 12 </option>
<option value="13"> 13 </option>
<option value="14"> 14 </option>
<option value="15"> 15 </option>
<option value="16"> 16 </option>
<option value="17"> 17 </option>
<option value="18"> 18 </option>
<option value="19"> 19 </option>
<option value="20"> 20 </option>
<option value="21"> 21 </option>
<option value="22"> 22 </option>
<option value="23"> 23 </option>
<option value="24"> 24 </option>
<option value="25"> 25 </option>
<option value="26"> 26 </option>
<option value="27"> 27 </option>
<option value="28"> 28 </option>
<option value="29"> 29 </option>
<option value="30"> 30 </option>
<option value="31"> 31 </option>
</select>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="card mt-3">
<div class="card-header">
<h5 class="mb-0">Agreement</h5>
</div>
<div class="card-body">
<div class="form-group row">
<div class="form-check" style="padding-left: 30px;">
<input class="form-check-input" type="checkbox" value="1" name="agreement" id="agreement" required="">
<label class="form-check-label" for="agreement"> By checking this box, I am electronically signing to authorize pass-travel-usa.com to use the information I provided on this form to generate a pre-filled passport form for me. I understand
that pass-travel-usa.com is a third-party and is not affiliated with any government agency. I agree to receive sms, email and calls about my order and to the privacy policy and terms and conditions listed on this website. I also affirm
the information listed above is accurate and truthful. I understand that the State Department provides forms and instructions for filings related to new, replacement, and updated passports at no charge. However, I request to use the
pass-travel-usa.com customized filing instructions to prepare my application based on the information I have provided. </label>
</div>
</div>
<div class="form-group row">
<!-- <label for="email-confirmation" class="col-sm-4 col-form-label">Add Signature</label> -->
<!-- <div class="col-sm-8">
<button type="button" class="ssn_add_signature btn btn-primary ml-2 mr-2">Add</button>
</div>
<textarea id="signature64" name="signed" style="display: none"></textarea> -->
</div>
</div>
<div class="form-group ml-3">
<button type="button" id="submit-btn" class="gform-btn btn btn-primary passport_submit_form btn-lg">Submit Application</button>
</div>
</div>
</form>Text Content
Pass Travel USA - US Passport START HERE: SERVICE TYPE Select Service What's Included? New Passport Renewal Passport Lost/Stolen Passport ABOUT THE APPLICANT Please select the document(s) you are applying for Passport Book Passport Card Both Do you need a regular or large passport book? Large passport book is recommended for Frequent Travelers. There is no additional fee. Regular Large Gender Male Female First Name Middle Name (Optional) Last Name Date of Birth Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 City of Birth Country of Birth Select country United States Afghanistan Akrotiri Sovereign Base Area Albania Algeria Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Ashmore And Cartier Islands Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Keeling Islands Colombia Comoros Congo Brazzaville Congo Kinshasa Cook Islands Coral Sea Islands Costa Rica Cote D Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Sovereign Base Area Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Islas Malvinas Faroe Islands Fiji Finland France French Polynesia French Southern And Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Federated States Of Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Romania Russia Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Wake Island Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe State of Birth Select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Middle East Armed Forces Americas Armed Forces Pacific Social Security Number Please confirm your SSN so that it is accurate. Your SSN is secured by latest SSL technology. Height Feet Select Height (ft.) 0 1 2 3 4 5 6 7 8 9 Inches Select Height (In.) 0 1 2 3 4 5 6 7 8 9 10 11 Hair Color Select Hair Color Black Blonde Brown Red Gray Other Eye Color Select Eye Color Amber Black Blue Brown Gray Green Hazel Occupation Employer/School (Optional) Former Name (Optional) List any other names you have used such as Birth Name, Maiden, Previous Marriage, or Legal Name Change. Only enter the name that was different. Former Name (Optional) List any other names you have used such as Birth Name, Maiden, Previous Marriage, or Legal Name Change. Only enter the name that was different. CONTACT INFORMATION Where should the passport be mailed? Street Address/RFD#, PO Box, or URB Street Address 2 (Include Apartment, Suite, etc) City Country Select country United States Afghanistan Akrotiri Sovereign Base Area Albania Algeria Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Ashmore And Cartier Islands Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Keeling Islands Colombia Comoros Congo Brazzaville Congo Kinshasa Cook Islands Coral Sea Islands Costa Rica Cote D Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Sovereign Base Area Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Islas Malvinas Faroe Islands Fiji Finland France French Polynesia French Southern And Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Federated States Of Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Romania Russia Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Wake Island Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe State Select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Middle East Armed Forces Americas Armed Forces Pacific Zip Code Is this your Permanent Address? Yes No Street Address/RFD#, PO Box, or URB Street Address 2 (Include Apartment, Suite, etc) City Country Select country United States Afghanistan Akrotiri Sovereign Base Area Albania Algeria Andorra Angola Anguilla Antarctica Antigua And Barbuda Argentina Armenia Aruba Ashmore And Cartier Islands Australia Austria Azerbaijan Bahamas Bahrain Baker Island Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia And Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Clipperton Island Cocos Keeling Islands Colombia Comoros Congo Brazzaville Congo Kinshasa Cook Islands Coral Sea Islands Costa Rica Cote D Ivoire Croatia Cuba Cyprus Czech Republic Denmark Dhekelia Sovereign Base Area Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Islas Malvinas Faroe Islands Fiji Finland France French Polynesia French Southern And Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guatemala Guernsey Guinea Guinea Bissau Guyana Haiti Heard Island And Mcdonald Islands Holy See Honduras Hong Kong Howland Island Hungary Iceland India Indonesia Iran Iraq Ireland Isle Of Man Israel Italy Jamaica Jan Mayen Japan Jarvis Island Jersey Johnston Atoll Jordan Kazakhstan Kenya Kingman Reef Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mayotte Mexico Micronesia Federated States Of Midway Islands Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Namibia Nauru Navassa Island Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands Norway Oman Pakistan Palau Palmyra Atoll Panama Papua New Guinea Paracel Islands Paraguay Peru Philippines Pitcairn Islands Poland Portugal Qatar Romania Russia Rwanda Saint Helena Saint Kitts And Nevis Saint Lucia Saint Pierre And Miquelon Saint Vincent And Grenadines Samoa San Marino Sao Tome And Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia And South Sandwich Islands Spain Spratly Islands Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad And Tobago Tunisia Turkey Turkmenistan Turks And Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands British Wake Island Wallis And Futuna Western Sahara Yemen Zambia Zimbabwe State Select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Middle East Armed Forces Americas Armed Forces Pacific Zip Code PREFERRED METHOD OF COMMUNICATION Preferred Method of Communication Mail Email Both Email Re-enter Email Phone Number Phone type Work Home Mobile Do you want to add additional phone numbers? No Yes Additional Phone Number Phone type Work Home Mobile Additional Phone Number Phone type Work Home Mobile TRAVEL PLANS (OPTIONAL) Complete this section only if you have known travel plans. If you do not have any travel plans yet, you can skip this section. Do you have any travel plans yet? Yes No Date Of Your Trip Year 2026 2025 2024 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Date Of Your Return Year 2026 2025 2024 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Countries To Be Visited? EMERGENCY CONTACT (OPTIONAL) Complete this section only if you have an emergency contact. If you do not have one, you can skip this section. Do you have an emergency contact that you would like to add to this application? Yes No Name of Emergency Contact Street Address/RFD#, PO Box, or URB Street Address 2 (Include Apartment, Suite, etc) City State Select state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States Of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico Virgin Islands Armed Forces Middle East Armed Forces Americas Armed Forces Pacific Zip Code Telephone Number Relationship to Applicant YOUR MOST RECENT PASSPORT Have you been issued any of the following? Passport Book Passport Card Both None Do you still have the book in your possession? Yes Yes, but it was Damaged or Mutilated No, it was lost No, it has been stolen Is your lost or stolen passport book expired? Yes No Unknown Have you reported your passport book lost or stolen book? Yes No The date your most recent passport book was issued (If Known) Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Your name as printed on your most recent book: First and Middle Name Last Name Book Number (If Known) Do you still have the card in your possession? Yes Yes, but it was Damaged or Mutilated No, it was lost No, it has been stolen Is your lost or stolen passport card expired? Yes No Unknown Have you reported your passport card lost or stolen card? Yes No The date your most recent passport card was issued (If Known) Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Your name as printed on your most recent card: First and Middle Name Last Name Card Number (If Known) Did you file a police report for your lost or stolen passport book or card? No Yes Do you want to order a new U.S. passport book and/or card? If yes, we'll provide your DS-11 form for no extra cost. No Yes Has your name changed since the passport was issued? No Yes State your full name that appeared on the lost or stolen passport LOST OR STOLEN BOOK INFORMATION Explain how the book was lost or stolen Where did the loss or theft occur? Provide the address if known (city/state or city/country) When was the book lost or stolen? If unknown, when was the last time you remember it being in your possession? Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 LOST OR STOLEN CARD INFORMATION Explain how the card was lost or stolen Where did the loss or theft occur? Provide the address if known (city/state or city/country) When was the card lost or stolen? If unknown, when was the last time you remember it being in your possession? Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 OTHER MISSING PASSPORTS INFORMATION Have you had another U.S. passport book/card lost or stolen? No Yes How many passports? Approximate date? Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Did you file a police report? No Yes Has your name changed since your most recent passport was issued? No Yes Reason for the name change? Marriage Court Order Do you have an official document to verify your name change? No Yes Date of Name Change Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Place of name change (City/State) APPLICANT'S PARENT INFORMATION Mother/Father/Parent Of Applicant Unknown First & Middle Name (at Parent's Birth) Last Name (at Parent's Birth) Date of birth (Optional) Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Place of Birth (Optional) Gender Male Female U.S. Citizen Yes No Mother/Father/Parent Of Applicant Unknown First & Middle Name (at Parent's Birth) Last Name (at Parent's Birth) Date of birth (Optional) Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Place of Birth (Optional) Gender Male Female U.S. Citizen Yes No SPOUSE OF APPLICANT Has Applicant Ever Been Married? Yes No Applicant's Spouse's Or Former Spouse's Full Name: Date of Birth Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Place of Birth U.S. Citizen Yes No Date Of Most Recent Marriage Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Has applicant ever been widowed or divorced? Yes No Date Year 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 1909 1908 1907 1906 1905 1904 1903 1902 1901 1900 Month 1 2 3 4 5 6 7 8 9 10 11 12 Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 AGREEMENT By checking this box, I am electronically signing to authorize pass-travel-usa.com to use the information I provided on this form to generate a pre-filled passport form for me. I understand that pass-travel-usa.com is a third-party and is not affiliated with any government agency. I agree to receive sms, email and calls about my order and to the privacy policy and terms and conditions listed on this website. I also affirm the information listed above is accurate and truthful. I understand that the State Department provides forms and instructions for filings related to new, replacement, and updated passports at no charge. However, I request to use the pass-travel-usa.com customized filing instructions to prepare my application based on the information I have provided. Submit Application