Scanned Document Collection Page | of 4 os » % “ U.S. PASSPORT RENEWAL APPLICATION FOR ELIGIBLE INDIVIDUALS ¢, ere ore - ag Tilenton Read VOARNING on page 1 of insructons Please select the document(s) for which you are applyin; assport Book... [] U.S_Palisport Cand Both wu uf iM! “|e Clo (lop sorscose _ —— Mitte GHISLAINE / NOELLE 2. Date of Birth (mevtityyyy) , 4 Pisce of Birth (Cy & State # jp the US. or City & Country #s @ is presently Anown) A * MAISONS LAFFITTE| FRANCE 8. Mailing Address: Line 1: StreevRFOS, P.O. Box, oF URB. Address Line 2: Cioanly iinet Arstmant Comeany, Sur Unit Rulding, Floo i Care Of or Attention it yoolcable. (@.g. in Care Of-.fane Doe, Apt 100) City Se Ze Caer Co cary ¢ out ce fe Unind States i NEW YORK NY 10065 1 9. List all other names you have used. (Exarples Birth Name, Maiden, Previous Mamage, Lega! Name Change Attach adkiitional pages if needed) A a 10, Passport Book andior Passport Card Information ; | Mon ‘Your name as listed on your most recent passport book andor passport cars GHISLAINE NOELLE MAXWELL Most recent passport book murier issue date (memttyyyy) | 12/04/2002 Most rece passport card number tesun date (mNeRyyyy) Change ioematiin. Snmonie trios we Got an inst 9ar=207 DOO = ReBsport card Crane > feet ace ofN ae C ange Ti) State) Ome cunda vy) (gad bb Sev* Or SxbI evita copy of your manage certicate or cov ender to separ your name Change Page tof? cdi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=CF15C41... 2/24/2020 EFTA00099206

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Scanned Document Collection eee ——— ‘ame of Applicant (Last, First 6 Moots) Date of Birth ymeveeiyyyy) MAXWELL, GHISLAINE NOELLE 12/25/1961 12 Meight 13. Heir Cole 14 Tyo Colne 16 cevpation 16, Employer or Schoo! ‘appicanie) 5ft. 8in. Brown Brown co SELF EMPLOYED 17 Additional Contact rnone Nunbers ‘48, Permanent Address: (PO fox 5 sled under Mading Address gr # residence is dtferent from Mading Access StreevRED # or URB (No P.O. Box} ApartmenyUret City ome Zip Code FL 33139 19 Emergency Contact Provide the information of @ person not raweing with you to be contacted in the event of an emergency Name Adcoess: SweeURFD #0 P.O Bax Apaetmantiuet 20. Trawe! Plans Date of Tre (mmaaayyyy) Duration of Trip Courtries to be visited 04/12/2012 2 WEEKS FRANCE i ; it ) = STOP! YOU HAVE COMPLETED YOUR APPLICATION BE SURE TO SIGN AND DATE PAGE ONE 05-82 12-2010 Page? Page 2 of 4 https://cedi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=CF15C41... 2/24/2020 EFTA00099207

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Scanned Document Collection Page 3 of 4 Letter of Authorization To: The US Passport Office Reproduction _ Passport Rush, LLC. to submit my passport and collect it when issued. BLLO-CRRS0000 The following visas are required prior to my departure: or Disclesure — PA Oia: { minor applicant Prohi bited https://ccdi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=CF15C41..._ 2/24/2020 EFTA00099208

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Scanned Document Collection Page 4 of 4 https://ccdi.state.osis.gov/pls/PPT/rpt_passport_images.display_doc_all?p_hash=CF15C41... 2/24/2020 EFTA00099209