PRISM Scanned Document

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U.S. Department of State
APPLICATION FOR: U.S. PASSPORT REGISTRATION
(Type or print all capital letters in blue or black ink in white areas only)

1. NAME (First and Middle): G H I S C L A I N E W O E L L E
LAST: MAXWELL
APT #: <empty>
STREET: <empty>
CITY: ST THOMAS
STATE: MS
ZIP CODE: 00802
COUNTRY / IN CARE OF (if applicable): C/O AMERICAN YACHT HARBOUR

2. MAIL PASSPORT TO: STREET / PO BOX; APT; CITY; STATE; ZIP CODE:
<empty>
<empty>
<empty>
<empty>

3. SEX:
[ ] M
[x] F

4. PLACE OF BIRTH (City & State of City & Country):
MAISON LAFITTE FRANCE

5. DATE OF BIRTH:
Month Day Year: <empty>

6. SOCIAL SECURITY NUMBER:
<empty>

7. HEIGHT:
Ft: 5
Inches: 3

8. HAIR COLOR: BROWN
9. EYE COLOR: BROWN
10. HOME TELEPHONE: <empty>
11. BUSINESS TELEPHONE: <empty>
12. OCCUPATION: BUSINESS OWNER

13. FATHER'S FULL NAME: MAKESI ADRIAN
BIRTHPLACE: KIGALI RWANDA
BIRTHDATE: <empty>
SEX: M
MOTHER'S FULL MAIDEN NAME: KABANGA ELIZABETH
BIRTHPLACE: KIBIRA RD KIGALI
BIRTHDATE: <empty>
SEX: F

14. HAVE YOU EVER BEEN MARRIED?
[ ] YES
[ ] NO

15. OTHER NAMES YOU HAVE USED:
<empty>

16. HAVE YOU EVER BEEN SUBJECT TO ANY FORM OF DOMESTIC ABUSE AT ANY TIME?
[ ] YES
[ ] NO

17. OTHER NAMES YOU HAVE USED:
<empty>

18. HAVE YOU EVER BEEN ISSUED A U.S. PASSPORT?
[ ] Yes
[x] No
IF YES, COMPLETE NEXT LINE AND SUBMIT PASSPORT IF AVAILABLE.
NAME IN WHICH ISSUED: <empty>
MOBILE/RECENT PASSPORT NUMBER: <empty>
MONTH DAY YEAR: <empty>
SUBMITTED: [ ]
LOST: [ ]
OTHER: <empty>

19. EMERGENCY CONTACT. If you wish, you may supply the name, address and telephone number of a person not traveling with you to be contacted in case of emergency.
NAME: <empty>
STREET: <empty>
CITY: <empty>
STATE: <empty>
ZIP CODE: <empty>
TELEPHONE: <empty>

20. TRAVEL PLANS (hot mandatory)
Month Day Year: 1 2 0 3 2 0 0 2
Length of Trip: 1 WEEK
COUNTRIES TO BE VISITED: UNITED KINGDOM

21. STOP. DO NOT SIGN APPLICATION UNTIL REQUESTED TO DO SO BY PERSON ADMINISTERING OATH.
I understand that under United States Citizenship Law, performed any of the acts listed under "Acts or Conditions" on the reverse of this application form unless explicit statement is attached. I solemnly swear (or affirm) that the statements made on this application are true and the photograph attached is a true likeness of me.

X <signature>
Amplified Signature - age 14 or older

X <signature>
Father's/Legal Guardian's Signature (if identifying minor)

X <signature>
Mother's/Legal Guardian's Signature (if identifying minor)

Month Day Year: 1 1 2 7 2 0 0 2
(SEAL)
Signature of person authorized to accept application: <signature>

22a. Applicant's or Father's Identifying Documents
Driver's License: [ ]
Passport: [x]
Other (Specify): NATURALIZATION CITIZENSHIP CERTIFICATE
Expiration Date: 11/27/2002
Place of Issue: St. Thomas
State: OHIO
Name: Chalaine N. Maxwell
ID No.: 2754548

22b. Mother's Identifying Documents
Driver's License: [ ]
Passport: [ ]
Other (Specify): <empty>
Expiration Date: <empty>
Place of Issue: <empty>
State: <empty>
Name: <empty>

24. FOR ISSUING OFFICE USE ONLY (Applicant's evidence of citizenship)
[ ] Birth Certificate
[ ] SR
[ ] CR
[ ] Passport
[ ] Passport Bearing's Name: SAME
[ ] Report of Birth:
[ ] Naturalization/Citizenship Cert No: DA 0748179
[ ] Other:
[ ] Seen & Returned:
[ ] Attached:

25.
FEE: $ 657 IA CK $ 0.00
MM DD YYYY: 1 2 3 1 0 2 0 0 1 1
OMB No.: 1405-0004 Expires: 12/31/2001 Estimated Burden - 20 Minutes
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