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إ رة از - Website: www.algeria
ّ ا Consulate General of Algeria New York ا ا رك از Passport Application Form إ ! رة :ا م First Name: ........................................................................................................................................... : ّ ا Surname: .............................................................................................................................................................................. ا ا ا ..................................................................................................................................... :د Maiden Name: : د ا ن $ و !ر " Date & place of birth:................................................................................................................... .................. .................................................................................................................................................... Father’s Name: :ا'م Mother’s Name & Surname...................................................................................................................... : :ا'ب إ و إ رة Photo . 1 ا./ ا ظ ا23 ا ة/ أر Current Occupation:............................................................................................................................................................................................................................ ........................................................................................................................................................................................................................ Marital Status: ..................... *ء/أ ب Address in the USA: Single ة/ وج Married: ة/. 4 Divorced Widowed: : . $!: ' ة ا1 ! ت اH اG ان ........................................................................................................................................ .... ............................................................................................................................................................................................................................................................................................................... STATE CITY Phone No. in the USA: ا ZIP CODE ............................................................................................................................................................................................. : . $!: ' ة ا1 ! ت اH اG I" D ر@ ا Email Address: ............................................................................................................................................................................................... : Eو: $ ! ا:>:. ا$!: ا' ان Address in Algeria :................................................................................................................................................................................................................. : : اC اG ان .................................................................................................................................................................................................................................................................................................................. ............. Date of Previous Consular Registration: :K* J ا ........................ ....................... ....................... ا F اCJ " ر! ا ر ا : Registration No:............................................................................................................................................................................................................................ Children to be included in the Passport Name م ا ّ ا Surname ................................................................ ................................................................ ........................ ....................... ....................... ................................................................ ................................................................ ........................ ....................... ....................... ................................................................ ................................................................ ........................ ....................... ....................... ................................................................ ................................................................ ........................ ....................... ....................... ................................................................ ................................................................ ........................ ....................... ....................... ................................................................ ................................................................ ........................ ....................... ....................... ا م Date of Declaration: ا Applicant’s Personal Description Date & Place of Birth ن ا د$ " ر! و 4ﺣ ا ف أو Height:.................................. ط لا Eyes:.............................. :< نا Hair: :: ; ن ا ........................... Special Peculiarities: ...................................... :ة ت ا Signature: ........................ ....................... ....................... Day Month Year X OFFICE USE ONLY Stamp Duty :............................................................. : .? ا.>!:3 . ص *)دارة- Psprt.Nr:......................................................................... : ازC ر@ ا : ! ": Extension:..................................................................... Renewal: ....................................................................... Office Decision :............................................................... : .A > ار ا:@ ........................................................................................................................................... Issuing Date: ........................ ....................... ................. Expiry Date:..................... ....................... :ار : ! C" " ر! ا :. ﺣF ء اD E" ر! إ .................... A 866 UN Plaza , Suite 580- New York, NY 10017 – Tél:212-486-69(30 to 32) –Fax: 212-486-6934 – Website www.algeria-cgny.org A © Name, Status & Signature of the Officer
