NIGERIA IMMIGRATION SERVICE
FRESH / RE-ISSUE E-PASSPORT
KWARA STATE COMMAND APPLICANT’S VERIFICATION FORM
TITLE: ____________________________________________________ DATE: ___________________________________________________________
SURNAME: ___________________________________________________________________________________________________________________
FIRST NAME: ________________________________________________________________________________________________________________
MIDDLE NAME: _____________________________________________________________________________________________________________
SEX: ________________ PASSPORT BOOKLET TYPE: 64/10 YEARS 64/5 YEARS 32/5 YEARS
DATE OF BIRTH: DAY: ___________________ MONTH: ____________________________________ YEAR: ____________________
NATIONAL IDENTITY NUMBER (NIN): __________________________________________________ HEIGHT (IN CM): __________
PLACE OF BIRTH: ___________________________________________________________________________________________________________
STATE OF ORIGIN: ________________________________________________ HOME TOWN: ________________________________________
PERMANENT ADDRESS: ___________________________________________________________________________________________________
________________________________________________________________________________________________________________________________
NATONALITY: ___________________________________ OCCUPATION: __________________________________________________________
LOCAL GOVT. OF ORIGIN: ________________________________________ MOBILE PHONE: _____________________________________
MARITAL STATUS: _______________________________ MAIDEN NAME (WOMEN ONLY): ____________________________________
DATE OF MARRIAGE: __________________________________________ PLACE OF MARRIAGE: __________________________________
EMAIL: ___________________________________________________ HAVE YOU OBTAINED E-PASSPORT BEFORE? YES/NO: ___
PASSPORT NO.: ____________________________________________ PLACE OF ISSUE: _____________________________________________
DATE OF ISSUE: __________________________________________ DATE OF EXPIRATION: _______________________________________
NEXT OF KIN: _______________________________________________________________________ RELATIONSHIP.: ____________________
ADDRESS OF NEXT OF KIN: ________________________________________________________________________________________________
______________________________________________________________________________ TOWN: _______________________________________
STATE: ________________________________________________ PHONE NO.: ___________________________________________________
This is to acknowledge that any false declaration on this form may lead to the withdrawal of the passport
(Miscellaneous Decree No. 15 of 1985 section 1 – 4). On no account shall I prove innocent of any of it if and
when committed.
APPLICANT’S SIGNATURE: _______________________________________________ DATE: _________________________________________
FOR OFFICIAL USE
Application Accepted/Rejected. Reason(s) for Rejection: __________________________________________________________
________________________________________________________________________________________________________________________________
Name of Approving Officer: ___________________________________________________ Rank: ________________________________
Signature of Approving Officer: ______________________________________________ Date: ________________________________
