Source document: https://docs-lawep.s3.us-east-2.amazonaws.com/1694491633411.pdf (Antigua and Barbuda)
For Official Use Only Application Number…………………………….

Application for Antigua and Barbuda Passport for Applicants Under 16 Years Form M Section 1 Personal Information.
Please refer to Note 1 Surname: ______________________________________________________________ First Name: ____________________________________________________________ Middle Name(s)_________________________________________________________ Marital Status: Single Married Divorced Widowed Separated Permanent Address________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Date of Birth ___/___/_____ Age_______ Place of Birth ____________________ dd mm yy Country of Birth: _______________________________ Sex: Male Female Height (ft)___________________________ Distinguishing Marks (if any) ________________________________________________ Telephone Number(s) ______________________________________________________ Section 2 Type of Application Please refer to Note 2 Standard Emergency Number of Pages Required: 32 64 2 Section 3 Reason for Application Please refer to Note 3 A) New (First Time) Issue F) Reissue Due to Name Change B) Reissue of Expired Passport F1) Reason for Name Change (tick below) C) Reissue of full Passport Marriage Adoption Deed Poll D) Reissue of Lost/stolen Passport G) Other (please specify) E) Reissue of Damaged Passport __________________________ __________________________ __________________________ __________________________ Section 4 National Status Please refer to Note 4 Citizen of Antigua and Barbuda by: i) Birth iii) Naturalization v) Registration pursuant to Citizenship by Investment Act ii) Descent iv) Registration vi) Registration pursuant to pursuant to the Citizenship Millennium Naturalization 2004 Act, Cap.
22 NB: If you are a citizen of Antigua and Barbuda by naturalization or registration, please complete the following: Certificate Number ______________________________________________________ Date of Issue ___________________________________________________________ Passport Number of Country of Birth ________________________________________ Place of Issue _________________________ Date of Issue______/______/_________ dd mm yy NB: If you are a citizen of Antigua and Barbuda by Investment, please complete the following Evidence of Citizenship __________________________________________________ Date of Issue ___________________________________________________________ Passport Number of Country of Birth ________________________________________ Place of Issue ________________________ Date of Issue______/______/_________ dd mm yy 3 Section 5 Were You Born Outside of Antigua and Barbuda?
Yes If yes, please refer to Note 5 and then complete this section No Father’s Details Full Name_______________________________________________________________ Place and Country of Birth _________________________________________________ Date of Birth _____/______/________ dd mm yy Mother’s Details Full Name______________________________________________________________ Place and Country of Birth _________________________________________________ Date of Birth _____/______/_______ dd mm yy Grandparent’s Details Full Name_______________________________________________________________ Place and Country of Birth _________________________________________________ Date of Birth ________/________/_________ dd mm yy NB If father, mother or grandparent is a citizen of Antigua and Barbuda by naturalization or registration, please complete the following: Number of his/her Document _______________ Place of Issue __________________ Date of Issue________/_________/_________ dd mm yy NB If applicant’s birth was registered at a Consulate of Antigua and Barbuda, please complete the following: Name of Consulate ______________________________________________________ Number of Certificate___________________ Date of Issue______/_______/_________ dd mm yy 4 Section 6 Supporting Documents Produced Please refer to Note 6 Both original and photocopies must be produced.
The following documents were submitted with the passport application: i) Birth Certificate ii) Baptismal Certificate iii) Marriage Certificate iv) Divorce Certificate v) Adoption Certificate vi) Proof of Legal Guardian vii) Deed Poll viii) Other (please specify) ______________________________ Section 7 Previous Passport Please refer to Note 7 Is the previous passport attached Yes No If yes, previous passport number ____________________________________ If no, go to section 8 Section 8 Lost/Stolen Passport Give details of the passport which has been lost or stolen Please refer to Note 8 Passport Number __________________________________________________ Place of Issue _____________________________________________________ Date of Issue __________/___________/_________ dd mm yy Your details at time of issue Surname ______________________________________________________________ First Name: ____________________________________________________________ Middle Name(s)_________________________________________________________ Marital Status: Single Married Divorced Widowed Separated Circumstances in which passport was lost or why it is not available: ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Place of Loss ___________________________ Date of Loss______/______/________ dd mm yy Has Loss Been Reported to the Police?
_______________________________________ 5 Section 9 Certification Please refer to Notes 9 and 10 *I certify that the applicant has been known personally to me for _______________________ (state period) and that the photograph which contains my signature, is a true photograph of the applicant.
Certifier: Full Name (block capitals) _________________________________________________ Occupation ______________________________________________________________ Address_________________________________________________________________ Contact Number (s)________________________________________________________ Signature _____________________________________ Date _____/______/______ dd mm yy Official Stamp Section 10 Parental Consent Please refer to Note 11 I/ We ___________________________________________________________________ (Please Print Given and Surnames) the_____________________________________________________________________ (Please State -Mother/Father/ Guardian) of ____________________________________________________________________ (Please Print Child’s Name) hereby give consent for him her to hold an Antigua and Barbuda passport.
Father’s Signature ___________________________ Date _______/________/_______ dd mm yy Mother’s Signature___________________________ Date _______/________/________ dd mm yy 6 Section 11 Supplementary Information Please refer to Note 12 ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Signature _____________________________________ Date______/_______/_______ dd mm yy Section 12 Declaration To be signed by all applicants.
Please refer to Note 13 I, the undersigned, hereby apply for the issue of a passport.

I declare that the information provided in this application is correct to the best of my knowledge and belief and that I have not renounced the status of Citizen of Antigua and Barbuda.
I further declare that any and all previous passports granted to me have been surrendered, other than the passport or travel document with the number specified in section __ of this form which is now attached and that no other application for a passport has been made since the attached passport or travel document was issued to me.

Signature ____________________________ Date _______/________/_________ dd mm yy NB: This section is to be signed by a parent or court appointed guardian.
7 Section 13 Signature To be signed by all applicants over the age of twelve (12) years Please refer to Note 14 IMPORTANT – DO NOT TOUCH THE LINES OF THE BOX Failure to comply with this instruction will invalidate the application.

FOR OFFICIAL USE ONLY Please do not write below this line CIP Registration No.
_____________________ Amount of Fee Paid ______________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________