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6g6u[ol, 15tgula6tol$ $amrrd;oorr.bDEPARTMENT OF IMMIGRATION AND EMIGRATION

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SRI LANKAN IDENTITY OVERSEAS

@ gozor co@d Ogergcsd, oQ8/rogel:roe6o@ esndzDcod esqem gdg@e:Ocs

@euraroro orqedr@, g6xrl/gl6olunerr& a.nairgipp eilouirauuuDAPPLICATION FOR A SRI LANKAN PASSPORT, EMERGENCY/ IDENTITY CERTIFICATE

e5666reD6o edtl oeo @?r)6e66 qrqgd zog eoedod 9o@8 rr)61@Od o@6rd OaOd qo6@eogo@Bocsd o@6paf 86Ecs 6tpo. OeO OdoO aqor 6ooqd er@zo:O O6del.

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The data anC information are fed into the computer only in English language. Hence the applicationmust be filled in English. Please read instructions sheet for further information.

zDrbcsr@Gco g@csJdQrco roeerl/ srg)r6)rei:a luGuropdpo Lcnodrlb/ For office use onlyAPPLICATION NO.

N

ALLOCATED PASSPORT NO. AC CODE

/a

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ql{sa6(3 'lureo)E I r<

Form )

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1. Type ofService

2. Type ofTravel Document

3. PresentTravel Document No. (lfany)

5. National ldentityCard No.

6. Surname

7. Names otherthan Surname

8. Permanent Address

i]

] r'ro,.r.r

] ntt cornt.i", Middle East f_l Emergercy [l tdentity

Countries I Certificare L_-l Certifiiate Ll

4. NMRP No. (lf any)

9. Date of Birth

1 0. Birth Certificate

1 1. Place of Birth

12. Sex

13. Profession/Occupation/Job

Date [t] Month m Year [T[flDistrict

ii]

Female tr Male tr

If Yes, Dual Citizenship No.

(Please fill up fields 1 7 and l 8 in the next page)

1 5. Mobile/ Phone No. (to be notified via SMS when passport is ready for collection)

trtr

one oay [l

'14. Have you obtained Dual Citizenship in Sri Lanka? ]

YestrNotr

] -" [T*I-il

16. E-mail Address

a

tt

District

tl

i

I

Compulsory for Dual Citizenship Holders

17. ForeignNationality

1 8. Foreign Passport No.

19. lf this application is for a child below the age of 16 years, following information must also be provided.Father / Guardian

National ldentity Card No. / PresentTravel Document No.Mother / Guardian

National Identity Card No. / PresentTravel Document No.

oeoo qedoOo @?Dro 6e?D Qg o{e) 9609 oelrcozoOel oOQ Oo0 qdtoer @Oer oOel@ tlOdel.dGp lenen @qnu$ e1@a'€,ri15enrqgLb gu:q Geu.rgl lusen eoaGlutnuugeo5 @rqLb, enaGtunriuLb a,@aofleb gorr6 mrrg1.

Please place your signature inside both cages below. Signature should not touch the border.

qcsag@eo6rod got<ocsleiimirorrLrupnryflair Lgrdlu1o)q / Declaration of the Applicant

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Etrmir @tD @eordrmau dJmgGueoqLb. GLoSGun$g oeoeurneil erprriesuur@dfidn gaereUaqryLb @oron6auur@enarg5oeonrioqgLb e flursureoelG)umqLb- leofieoL-ournsuarauGuenqLb gEErrdD lEglqarry6dlairGpair. g6up[6ur / Guno$Jurronegar:emimamarri eoqur5uugl gruireordgfl u g$pLongG)roorirueogqLb pnair erf Gelair.

I declare that I am a citizen of Sri Lanka and the above information furnished by me and the documents attached hereto are trueand correct.Also, I am aware of the fact that producing forged/falsified documents and information is a punishable offence.

Qercs/pla$ /Date qcsag@todaocd qdmel / olemireo'ornugnfl u51air eosGlunrluLb

22.

Signature of the Applicant

tDlb63l@Eco g@csJd€rco eocerl/€xsi6il6Da ruGu,Lirapbdpto ,ngdlrLolForofficeUseonly

Controiler's Order Minute Sheet Attached (lf any)

De;A&;;;i;;;

PPT No:

PPT Lost: YeS/No

Police Report /TTD i NMRP

Dual Citizen: Yes / No

BC No. & District:

NIC / DL / Postal ID

MC No. & District

F's PPT / NIC Copy & Concent Letter

M's PPT / NIC Copy & Concent Letter

DC / AC's Order:

Pending at Computer Division

tl

21

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