Scanned Document Collection Page | of 3 SPa 4% / /2 ee APPLICATION FOR A U.S. PASSPORT BY MAIL OMB APPROVAL XC Attention: see WARNING on page two of instructions Please select the document (or documents) for which you are applying: =x]U,S. PassportBook eT] U.S)PassndithCard he US peenpo't cant ray ony Ine Uke for \ernwtnies trey Dy len or see letaneh the United Sines areca, Meme, the Cay tOeen anc fermuce Purse opt ow wedete lr Cotaued ehumyon ————————————— MAXWELL First & Middle GHISLAINE NOELLE 4. Place of Birth (City & State or City & Country as it & presently known) Ce MAISONS LAFITTE, FRANCE 6. Mailing Address: Street/RFD # or P.O. Box State Zip Code (ap + 4" known) a NEW YORK = ©: Bel. 0065 10, Passport Book or Passport C; informatio Er One ET Most necent passport book or passport card Issue date (mmydd/yryy) 11. Name Change Information - Complete if name és different thar) last passport book or passport card Place of Name are oO Change (Oty/State) (maniad/yyvy) ] Gitioged by Court Order || Se ne ae name Hany: ratoraity, of thes applicabon (unless it ts attached); Statements Of induded fase Gocuments © support of this Nave read and understood the warning on page two of the structions 80 0S-82 02-2008 ct SS AuzA ATT mitt y cedi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00099203

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Scanned Document Collection Page 2 of 3 14. Color 15. Occupation ——— =r ee i= 0 ] RROWN Lom, 8 BUSINESSWOMAN 1 ee SS — 19, Emergency Contact - Provide the information of a person not reveling with you to be contacted in the event of an emergency. : Name Address: Street/RFD # or P.O, Box oa tN 20. Travel Plan. Date of Trip (mumnyad/yywy) gh orp 4 MONTHS BE SURE TO SIGN AND DATE PAGE ONE Glos Yomer- Deecte | jenn Ate EFC 0S 8210 20072 Page 2 of 2 0S-82 02-2008 2/24/2020 https://ccdi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... EFTA00099204

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Scanned Document Collection Page 3 of 3 travisa Wien You Need Kh Fasi™ Since 1981 Travisa Passport & Visa Service Date; May 4%, 2008 = Namie: © Maw . Ghisleine Noelle S Fir, Middle) Date of Birth: cantar Ad, 1961 Place of Birth: FRrawe é | AUTHORIZE TRAVISA PASSPORT & VISA SERVICE TO SUBMIT MY PASSPORT APPLICATION TO A U.S. PASSPORT AGENCY, AND TO ACCEPT DELIVERY OF THE PASSPORT ON MY BEHALF. Under the provisions of the Privacy Act of 1974 (Public Law 93-579,) no information may be released from U.S. Government files without prior written consent of the individual in question. ¥ ae rumen a Peesport Agency cannot discuss the details of your passport application with Travisa Passport & Visa Service without your perv ission. Please choose one of the following: J authorize the U.S. Peesport Agency to discuss any problems which may arise with my Passport application with Travisa Passport & Visa Service. oO | want the U.S. Passport Agency to contact me directly should a problem arise with my which concerns matters other than the date on which the passport https://cedi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=42994A0... 2/24/2020 EFTA00099205