Standard ePassport Registration Form
ATTENTION: THIS FORM APPLYS TO THE ATLANTA,NEW YORK CONSULATE AND WASHINGTON DC EMBASSY UPON SELECTION, FIND THE OPTION BELOW.
1 - PASSPORT PAGE INFORMATION
FILL IN THE BLANKS WITH THE INFORMATION FOUND IN YOUR PASSPORT DATA PAGE
Applicant Name
*
First Name
Middle Name
Last Name
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
*
Please Select
Male
Female
N/A
National Identity Number
*
NIN # 00000000000
Passport Number (Required If Available)
A12345678
Processing Embassy in the US
*
Please Select
Atlanta
Washington DC
New York
Type of Passport Application
*
Please Select
Renewal Application
Fresh or first time Passport Application
Lost Passport Application
Change of data Application (name/dob)
Damaged Passport Application
Passport Validity
*
Please Select
5 Years
10 Years
2 - YOUR PERSONAL INFORMATION
Marital Status
*
Please Select
Married
Single
Divorced
Widowed
MOTHERS MAIDEN NAME
*
MOTHERS MAIDEN NAME
YOUR OCCUPATION
*
YOUR OCCUPATION
State of Origin In Nigeria
*
Please Select
• Abia
• Adamawa
• Akwa Ibom
• Anambra
• Bauchi
• Bayelsa
• Benue
• Borno
• Cross River
• Delta
• Ebonyi
• Edo
• Ekiti
• Enugu
• Gombe
• Imo
• Jigawa
• Kaduna
• Kano
• Katsina
• Kebbi
• Kogi
• Kwara
• Lagos
• Nasarawa
• Niger
• Ogun
• Ondo
• Osun
• Oyo
• Plateau
• Rivers
• Sokoto
• Taraba
• Yobe
• Zamfara
State of Origin In Nigeria
Home Town In Nigeria
*
3 - YOUR AMERICAN INFORMATION
YOUR AMERICAN CONTACT INFORMATION AND ADDRESS
American Phone Number
*
E-mail
*
example@example.com
American Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
4- NEXT OF KIN NIGERIAN INFORMATION
NEXT OF KIN ADDRESS AND CONTACT INFORMATION MUST BE NIGERIAN
Next Of Kin Name
*
First Name
Last Name
Relationship with the applicant
*
Next Of Kin Nigerian Mobile Number
*
080 0000 0000
Next Of Kin Address In Nigerian (Must be a Nigerian Address)
*
Nigerian Street Address
Street Address Line 2
City
State
Local Government Area
Additional Comments (Personal Request)
Signature
*
I have understood and accepted all Terms and Conditions inclusive of the government and processing fees, which are non-refundable and required to process my application.
*
Select Payment Option
*
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Passport Fee 5 years
$162.00 Service Fee $39
$
201.00
Passport Fee 10 years
$262.00 Service Fee $39 Attention!!! Minor 0-17 are not eligible for 10 years passport.
$
301.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Please click one of the PayPal options to complete payment and
submit
the form.
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