THIS IS THE APPLICATION ~ PRINT THIS PAGE!!!

PLEASE ALLOW 4-6 WEEKS
TO PROCESS. INTERNATIONAL
ORDERS TAKE 6-8 WEEKS. THANK
YOU FOR YOUR PATIENCE.

Form CR-AppCit-2A
STAFF USE ONLY: ****

Passport #_________________
EXP. DATE ____/____/____

IMPORTANT INSTRUCTIONS: FEE MUST BE PAID IN U.S. FUNDS (U.S. DOLLARS ONLY!) (No Personal Checks) For orders within the USA/Canada: Remit $100.00 US for each passport (Shipping included) For Orders outside of the United States: Remit $118.00 US per passport by International Money Order in U.S. Funds . (Shipping by Registered mail is included in this price.) Make payment out to "Passport Control" and send application and payment to: THE CONCH REPUBLIC OFFICE OF THE SECRETARY GENERAL 613 SIMONTON STREET KEY WEST, FL - US 33040 IMPORTANT NOTE: Applicant must attach a Notarized Copy of applicant's passport or other Official Identification from country of residence. APPLICATION CAN NOT BE PROCESSED WITHOUT THIS NOTARIZED DOCUMENTATION! You must include 3 - photos suitable for cropping to passport size, a completed application form and payment for each passport ordered.
(Please Print or Type clearly - Be sure to sign your application and the Oath!)
Name of applicant: First		Middle			Last/Family
Street Address, Unit #, Suite, etc.
City		State		Country			ZIPCODE
Daytime phone			Email Address
Date of Birth (dd/mm/yyyy)			Place of Birth
Sex(M/F)	Eye color	Hair color		Height		Weight
Distinguishing marks (Tattoos, Scars, Piercings, etc.)
APPLICANT AFFIDAVIT The undersigned applicant for citizenship in the Conch Republic solemnly swears that they have never been convicted of a Serious Crime involving life or property, and that they are of good character. Signature of applicant__________________________________ Date____/____/______

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Credit Card Authorization For US and Canadian Payment Only Shipping address and Billing address must be the same! This information must be included if you are paying by Credit Card. Passports will only be shipped to the Credit Card Billing Address Only Visa / MasterCard are accepted at this time.
(Card Type-Circle One: Visa / Mastercard)
Card Holder Name as on Card
Card Number		Exp. Date (mm/yy)
Phone Number of Cardholder
Billing Address for Credit Card (For AVS Verification)
Name
Address
City	State	Zipcode
I authorize Conch Republic Passport Control to charge the herein listed credit card my credit card for the amount indicated in this application.
Signature of Card Holder		Date: (dd/mm/yyyy)
Cardholder must sign above on Credit card purchases. Credit Cards will be accepted on US & Canadian Orders Only.

Your Passport will be issued by, the Office of the Secretary General.
Please allow 4-6 weeks for processing.