DATE: ___________________

TO: DEPARTMENT OF FOREIGN AFFAIRS – NCR NORTH

PASSPORT DELIVERY AUTHORIZATION

I authorize my representative whose name and signature appear below to receive my PASSPORT on my
behalf. I am leaving authorized representative our unexpired ID’s as follows:

OWNER’S ID REPRESENTATIVE’S ID

UMID UMID

I am aware that Department of Foreign Affairs (DFA) highly recommends that I personally receive my
passport as a safety measure. In this regard, I will hold free and harmless, as well as indemnify DFA from
any actions, claims, damages, and/or charges arising from the use of my passport received through my
authorized representative as indicated below.

______________________________ _______________________________

Signature over printed name of the owner Signature over printed name of representative