Form DS-4085 Application for Additional VISA PAges

OMB APROVAL NO. 1405-0159
EXPIRES: XX/XX/XXXX
ESTIMATED BURDEN: See Instruction Page 2

US DEPARTMENT OF STATE

APPLICATION FOR ADDITIONAL VISA PAGES
WARNING: False statements made knowingly and willfully in passport applications or in affidavits or other
supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of
18 USC 1001, 18 USC 1542 and/or 18 USC 1621. Alteration or mutilation of a passport issued pursuant to
this application is punishable by fine and/or imprisonment under the provisions of 18 USC 1543. The use of a
passport in violation of the restrictions contained therein or of the passport regulations is punishable by fine
and/or imprisonment under 18 USC 1544. All statements and documents are subject to verification.

When completing this form, PRINT IN BLUE OR BLACK INK ONLY.
1. Name of Applicant
Last

Suffix (Jr., Sr., III)

First

Middle

2. Date of Birth

3. Sex

4. Place of Birth (State OR Country) 5. Social Security
(See Federal Tax Law Notice on Instruction Page 2)

(mm/dd/yyyy)

Male

6. Mail My Passport To:
Apartment #

Street / RFD # OR Post Office Box
City
Country

State
In care of

(If outside the US)

Zip Code

(if applicable)

7. Permanent Address or Residence (DO NOT LIST P.O. BOX) (If same as mailing address write “Same As Above”)
Street / RFD #

Apartment #

City

State

Zip Code

8. Home Telephone (Include Area Code)

9. Business Telephone (Include Area Code)

(

(

)

10. E-Mail Address (Optional)

)

11. Passport Information
Name as it appears on U.S. passport

Issuance Date

Passport Number

12. Departure Date

13. Countries to be Visited

14. Oath & Signature
I declare under penalty of perjury that I am a United States citizen (or non-citizen national) and have not, since acquiring United States citizenship (or US
nationality), performed any of the acts listed under “Acts or Conditions” on the reverse of this application form (unless explanatory statement is attached).
I declare under penalty of perjury that the statements made on this application are true and correct.

X
Applicant’s Signature

Date

FOR PASSPORT SERVICES USE ONLY

APPLICATION APPROVAL

DS-4085
6/2005

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