f'or fsm passport - Micronesia Embassy

I intend to travel to ttrc following countries for tre following periods and purposes.
(courvrR9 (Co{JNIRY) (coUr{rRY)
(couNrRY)
My last Travel Docunent was obtaind from
ard is submited herewith for cancellation
My photograph likeness and penonal description are giran belovr
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Itreiglre _Fet:
l l SIGNATURE
Subaaibed ard surom o before rB this: Dayof
NOTARY
PERSONALDESCRIPTION
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Distinguiching noad$ q features:
Evidence rnry be addrced as follows ttut tre applicarf is a citizen of tre Federated States of Microrpsi4 that he is not a rntional of any
foreign courfry, and fiat he does not bear allegiance to any foreign country. (A corrylete staternent stpuld be furnisbed urder this zubdivision
indicating tre natue of the widence wtrich was obtaine4 such as (l) records as to birth, nrarriage, etc. (2)Penqnl interrogation of trc
applicaff, (3Interrogation of rnembers of tbe claq tribe, or comrnrnity, or (4) Whateraer other investigation is neessary in order to esablish
ttr,at the applicant is a citizen ofthe Federated States of Micronesia)
I tueby cenify that I am s*isfied tlat ttre applcant is a citizen of tbe Federated Sttes of Micruresi4 and tbat he./she does not owe
allegiarrce o any foreigrrcoury.
Age:
IMMIGRATION AND LABOR OFFICER
Date
20