1PaspoortaanvraagformulierPassport application form

(Svp invullen in blokletters met blauwe of zwarte pen)(Please print with blue or black pen)

FOR OFFICIAL USE ONLY

No.

Location C/

DateTariff:C / E $

1. a Aanvraag betreft kinderpaspoort (t/m 15 jaar) paspoort zakenpaspoort laissez-passerApplication for child passport (15 years inclusive) passport business passport laissez-passer

nooddocument anders,namelijk ..emergency passport other, namely

b Vermelding kinderen kinderbijschrijving (sticker in bestaand pasp.) kinderbijschrijving (bij aanvraag nieuw pasp.)Inclusion of children inclusion of child in current passport inclusion of child in new passport

2. Naam aanvrager (indien van toepassing naam voor huwelijk/geregistreerd partnerschap)Family name of applicant (if applicable name before marriage/reistered pasrtnership)

.

3. Voornamen(voluit) Given names (in full)

4. Geboortedatum . 5. Geboorteplaats- en land ...Date of birth Place and country of birth

6. Lengte aanvrager . cm. 7. Geslachtman vrouwheight of applicant Gender male female

8. Adres (volledig, geen PO Box)..Address (complete, not PO Box)

............... Postcode . tijdelijk (temporary) vast (permanent)telefoonnr. (tussen 09.00 & 16.00 uur) ... mobielnr: ...telephone number (between 9 am and 4 pm) (mobile no.)E-mailadres .

Burgerservicenummer (indien bekend)Citizen-service-number

9. Gegevens huidige Nederlands paspoort: paspoortnummer .. datum afgifte ..Details current Netherlands passport passport number date of issue

afgegeven door ...issued by

Indien u dit paspoort niet kunt overleggen, wat is daarvan de reden?If you cannot show your passport, what is the reason?

eerste aanvraag verlies/vermissing anders, namelijkfirst application lost/missing other, namely

10. Burgerlijke staat aanvrager ongehuwd gehuwd gescheiden weduwe/weduwnaar gereg. partnerschapMarital status of applicant single married divorced widow/widower registered partnership

11. alleen invullen indien u wenst dat de naam van uw (voormalig) echtgeno(o)t(e) of partner in uw paspoort wordtbijgeschreven (tevens indien al bijgeschreven in huidig paspoort)only to be completed if you wish to have your (ex) husband's or wife's name added in your passport (even if already included in your present passport)

Achternaam echtgeno(o)t(e) of partner...........Surname of husband/wife or partnerDatum en plaats huwelijk/registratie..Date and place marriage/registrationDatum en plaats van ontbinding huwelijk/registratie...Date and place of dissolution of marriage/registration

12a.Op welke wijze heeft u de Nederlandse nationaliteit verkregen?How did you obtain Netherlands nationality?geboorte huwelijk naturalisatie optie adoptie

birth marriage naturalisation option adoption

12b.Op welke wijze heeft(hebben) uw ouder(s) de Nederlandse nationaliteit verkregen?How did your parent(s) ontain the Netherlands nationality?geboorte huwelijk naturalisatie optie adoptie

birth marriage naturalisation option adoption

212c.Bezit(ten) uw ouder(s) nog steeds (of ten tijde van overlijden) de Nederlandse nationaliteit?Does (do) your parent(s) still (or at the moment of death) hold the Netherlands nationality? ja / yes nee / no

12d.Indien nee: wanneer heeft(hebben) uw ouder(s) de Nederlandse nationaliteit verloren? ..If no: when did your parent(s) lose the Netherlands nationality?

13. Bezit u naast de Nederlandse nationaliteit nog andere nationaliteiten? nee / no ja / yesApart from Netherlands nationality, do you possess other nationalities?

14. Welke andere nationaliteit(en) bezit u thans..What other nationalit(y)(ties) do you possessHoe en wanneer heeft u deze verkregen?....How and when did you obtain these?

15. Bezit u behalve een Nederlands paspoort- nog andere (Nederlandse of buitenlandse) paspoort(en) of foto identiteits-bewijzen zoals een rijbewijs?Do you possess - other than a Netherlands passport - other (Netherlands or foreign) passport(s) or photo identity papers such as a driver's licence?

nee ja, namelijk: ..no yes, namely:

16. Gegevens van kind(eren) t/m 15 jaar (vragen 16 en 17 alleen invullen indien u een kinderbijschrijving wenst)Details of child(ren) until 15 years(inclusive) (questions 16 and 17 only to be completed if a child is to be included in your passport)

Naam Voornamen Geboortedatum Geboorteplaats m/v Nationaliteit (en)Surname Given names Date of birth Place of birth m/f nationalit(y)(ies)

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17. Heeft u het wettig gezag over deze kinderen? ja neeDo you have legal custody of these children? yes no

18. Sinds wanneer verblijft u hier te lande? Since when have you lived in this country?

19. Heeft u een verblijfsvergunning? ..Do you have a residence permit?

20. Wat was uw laatste woonplaats in Nederland?What was your last place of residence in the Netherlands?

21. In welk jaar bent u daar vertrokken? In what year did you leave the Netherlands?

22. Heeft u zich laten uitschrijven? Did you have your name removed from the municipal registry?

23. Eventuele opmerkingen van de aanvrager Remarks by the applicant

Ik, ondergetekende, verklaar hiermede uitdrukkelijk dat bovenstaande gegevens naar waarheid door mij zijn verstrekt en dat deingeleverde fotos mij voorstellen. Ik verklaar hiermede tevens uitdrukkelijk dat ik het Nederlanderschap niet heb verloren doorvrijwillige verkrijging van een andere nationaliteit, danwel op enige andere wijze mij bekend, zodat ik naar mijn beste weten deNederlandse nationaliteit bezit.I, the undersigned, declare herewith that I have answered the above questions truthfully and that the photographs provided are an image of myself. In addition Ideclare that I have not lost Netherlands nationality by freely adopting another nationality, or by obtaining another nationality by any other means known to me,so that I can declare to the best of my knowledge that I possess Netherlands nationality.

Plaats Datum Place DateHandtekening aanvrager:Signature applicant

3Indien deze aanvraag betrekking heeft op een minderjarige (t/m 17 jaar), of indien wordt gevraagd om bijschrijving van n of meerminderjarigen in een paspoort, dan dienen de vader en moeder (mits zij gezamenlijk het ouderlijk gezag uitoefenen) dan wel de personendie het gezag uitoefenen door ondertekening van dit formulier te verklaren dat zij instemmen met de gevraagde handeling. (zie ook pag. 4)If this application is in regard to an under-aged person (until 17 years inclusive), or if the request concerns having one or more under-aged persons added to thepassport, then the father and mother, if they both have legal custody, or the legal guardians, need to declare - by signing hereunder - that they agree with therequest as stated.(see also page 4)

Plaats .. Datum Place DateNaam vader/persoon die Naam moeder/persoon diehet ouderlijk gezag heeft het ouderlijk gezag heeftName father/guardian Name mother/guardian

Handtekening: . Handtekening:Signature Signature

Opmerkingen / Remarks :1. Bij het aanvragen van een nieuw reisdocument moet naast het oude paspoort n kleuren pasfoto worden ingeleverd. Informatie over de

voorwaarden van de paspoortfoto kunt u vinden op de volgende website: www.paspoortinformatie.nl, of neem contact op met het NederlandsConsulaat(-Generaal)/Ambassade in uw regio. Adressen van een fotograaf in de buurt van het Consulaat(-Generaal)/Ambassade zijn te vindenop onze website www.mfa.nl/can.Please enclose one colour passport photograph. Instructions of the requirements for the passport photograph can be found on the followingwebsite: www.paspoortinformatie.nl, or contact the Netherlands Consulate(-General)/Embassy in your region. Addresses of a photographerin the vicinity of the Consulate(-General)/Embassy can be found on our website www.mfa.nl/can.

2. De voor het paspoort verschuldigde rechten (zie www.mfa.nl/can) dienen bij de aanvraag te worden voldaan.The passport fee needs to be paid at the time of the application (see www.mfa.nl/can).

3. Indien de aanvrager nog niet eerder in het bezit van een Nederlands paspoort is geweest, dient duidelijk te worden aangegeven op welke wijzehet Nederlanderschap is verkregen. Ter vaststelling van de nationaliteit en de identiteit van de aanvrager dienen voldoende bewijsstukken,waaronder in ieder geval de zonodig gelegaliseerde geboorteakte, te worden overgelegd.In case of first application for a Netherlands passport, the applicant needs to state clearly how he/she obtained the Netherlands nationality.To be able to acknowledge the applicant's nationality and identity, he/she would need to supply adequate documents, one of which being alegalised birth certificate.

4. Indien de aanvrager niet in staat is een hem of haar eerder afgegeven Nederlands reisdocument over te leggen, dient een schriftelijkeverklaring omtrent de vermissing te worden afgelegd. (verkrijgbaar bij het consulaat/ambassade waar u de aanvraag indient)If the applicant is unable to produce the previously issued Netherlands travel document, then a written declaration in regards to the loss is re-quired (available from the consulate/ embassy where you apply).

5. De bijschrijving van een kind in een reisdocument wordt ongeldig op het moment dat het kind de leeftijd van 16 jaar heeft bereikt. (alleen nogmogelijk tot 26 juni 2012).The inclusion of a child in a passport becomes invalid at the time the child reaches the age of 16 years (only possible till 26 June 2012).

RequirementsPlease bring the following documentation: Current Netherlands passport plus a valid identification (driver's licence or Australian passport); If passport is lost please report to police and bring police notification number; All other current passports issued to you if you possess another nationality besides Netherlands nationality; One passport photograph as described under remarks above (also of children if they are to be included in your passport, ensure

that no hands are showing on passport photos for babies): Please note that if the photo is not according to the specificrequirements, a new photo will be requested.

(Only with first application) Birth certificate*(see page 4), also of the children if they are to be included in your passport(inclusions only valid until 26 June 2012). If born in the Netherlands you can obtain this from the city hall (gemeentehuis)where you were born; if born in Australia from Registry of Births, Deaths and Marriages; otherwise from the authorities in thecountry where you were born;

Copy of marriage certificate if you want the name of your husband/wife added in your passport and it has not already beenincluded;

If the application is for a person not yet eighteen years of age when the last passport was issued, or a first application for childunder eighteen years of age, proof must be provided that one of the parents is/was still a Netherlands citizen when the childturned eighteen years of age (copy of valid Netherlands passport and valid visa);

For payment passport fee we accept cash (exact money, no change can be given), money order or bank cheque. The Embassyin Canberra only accepts payments in cash. At the Consulate-General in Sydney you can also pay by EFTPOS (not by creditcard). The current fee is listed on our website (www.mfa.nl/can > List of fees).

Passports are issued by the Consulate General in Sydney and the Embassy in Canberra. If you're not collecting at the ConsulateGeneral in Sydney or Embassy in Canberra, you will have to supply a self-addressed registered mail envelope (A4 sizeenvelope) or Platinum Express envelope. Other envelopes cannot be accepted.

>>>>> As each application will be looked at individually further information / documentation may be requested.

4IMPORTANT (please read)Applications must be submitted in person (including children) at your nearest Consulate(-General) or Embassy. Application of aperson under the age of eighteen: both parents must sign the application form. If (both) parent(s) do not attend, a StatutoryDeclaration of parent(s) who give(s) permission for child(ren) to have a Netherlands passport, together with a certified copy of avalid passport for verification of signature must be provided. If parents are divorced and the other parent will not/cannot sign theapplication form, proof of full legal custody of the child(ren) must be provided

* The certificates (date of issue within six months of the passport application, except for naturalisation certificates) must be originalsor an extract of the originals. All foreign documents must be legalised / authenticated by the appropriate authorities, for instance,Australian documents must be authenticated by the Australian Department of Foreign Affairs with a so-called "Apostille"-stamp.The Apostille-stamp MUST be on the original document not on a photocopy. Please note that for NSW de Apostille stamp will beprovided by the Authentications Section of the Sydney Passport Office.

Please bring all original documents and a photocopy of all the documents, including the drivers license.APPLICATIONS FOR A NEW PASSPORT CAN TAKE BETWEEN 2 AND 5 WEEKS (after all the required documents havebeen received)

If you are a Netherlands citizen and became an Australian citizen after 1st April 2003 and were married to an Australian citizen at thetime of naturalisation the following extra documents are required: Naturalisation Certificate*. Marriage certificate* (from Registry of Births, Deaths and Marriages, phone: 1300655236). Proof that at the time you became an Australian citizen, your wife/husband was an Australian citizen (e.g. Australian birth certificate*

together with copy of Australian passport or Australian certificate of naturalisation*). A letter from the Family Court that you are not divorced at the time of your naturalisation.

If you are a Netherlands citizen and became an Australian citizen after 1st April 2003 and you lived in Australia for an uninterruptedperiod of at least five years before you turned eighteen, the following extra documents are required: Naturalisation Certificate*. Proof that you lived in Australia for an uninterrupted period of at least five years before you turned eighteen. This proof to be delivered by

means of a record from the Department of Immigration Archives in Canberra or a letter from the Department of Immigration stating whenyou arrived in Australia AND "Record of Movement" from the Immigration Department and/or your school records.

SYDNEY, Consulate-General of the NetherlandsTower 2, Level 23, 101 Grafton StreetBondi Junction NSW 2022Tel. 02-9387 6644 (between 10 am and 1 pm) Fax. 02-9387 3962Open to the public Mon-Fri 10 am - 1 pmWebsite: www.mfa.nl/can

CANBERRA, Royal Netherlands Embassy120 Empire Circuit,Yarralumla ACT 2600Tel. 02-6220 9400 Fax. 02-6273 3206Open to the public Mon-Fri 9.00 am - 12.30 pmWebsite: www.mfa.nl/can

ADELAIDE, Consulate of the NetherlandsLevel 1, 147 Frome Street, Adelaide SA 5000(Enter via 139 Frome Street), Tel. 08-8232 3855 Fax: 08-8223 3836Open to the public Mon-Fri 9 am - 5 pm BY APPOINTMENT ONLY

MELBOURNE, Consulate of the NetherlandsLevel 3, 50 Market Street, Melbourne VIC 3000Tel. 03-9620 2701 Fax: 03-9620 9270Open to the public Mon-Fri 10 am - 2 pm BY APPOINTMENT ONLY

BRISBANE, Consulate of the NetherlandsSuite 2, "Bellevue Terrace", 25 Mary Street, Brisbane QLD 4000Tel. 07-3839 9644 Fax: 07-3839 2176Open to the public Mon-Fri 10 am - 12 pmBY APPOINTMENT ONLY

PERTH, Consulate of the NetherlandsOffice B, 1139 Hay Street, West PerthTel. 08-9486 1579 Fax: 08-9321 6410Open to the public Mon, Tue,Thu, Fri 10 am - 12 pmBY APPOINTMENT ONLYPORT MORESBY, Consulate of the Netherlands - PNGSection 209 Lot 1, Spring Garden Road HoholaTel. 0011 675 325 4177E-mail: dsbrown@pngmail.net

binnenkomst kassa nakijken invoeren Brief uit Volledig Paspoortverzonden

Beschikkingverzonden

Oude paspoort: Vermist / Ongeldig retour Tarief: