Form 19

EPP1-R7TO62OA | R 1113420
(Revised 2012)

Receiving Officer
OMBI LA KUTAKA PASPOTI YA KENYA
APPLICATION FOR A KENYA PASSPORT Name ......................................................

Signature................................................
Majina Kamili / Full Names JAMES BUSIENEI YABAN Stamp .....................................................

Indexing Officer

Tafadhali soma maagizo kwa makini kabla ya kujaza fomu Name ......................................................
Please read instructions carefully before completing the form Signature................................................

Stamp .....................................................

MAAGIZO INSTRUCTIONS

1. Maelezo: Tafadhali ufahamu vyema kwamba wale wote 1. Instructions. Kindly note that all applicants must complete all
wanaoomba paspoti ni lazima wajaze Sehemu zote. Sehemu ya 3, Sections. Section 3 must be completed where the applicant is married
ni lazima kujazwa na mwombaji ambaye ni mwanamke aliyeolewa. and evidence of the same produced. After filling the application form,
Baada ya kujaza fomu kwenye mtandao, chapisha nakala you download, print, sign and go with the signed copy to immigration
nauiwakilishe kwenya ofisi ya paspoti. offices.
2. Upendekezi wa ombi.Baada ya kuchapisha nakala ya fomu 2. Recommendation of application. Recommendation of
uliyoijaza, mwombaji lazima apendekezwe katika sehemu ya 7 na application. After downloading and printing the completed application
mwananchi wa Kenya ambaye anamfahamu mwombaji, lakini forms, the application must be recommended in Section 7 by a citizen
asiwe jamaa wakaribu. of Kenya, who personally knows the applicant but not an immidiate
3. Picha. Picha tatu zilizopigwa hivi karibuni lazima ziambatane na relative.
fomu. Picha hizi lazima ziwe za uso wote, bila kuvaa kofia au 3. Photographs. A digital copy of a recent photograph of the
kitambaa. Pia picha isiwe ndani ya fremu. Ukubwa wa picha usizidi applicant must be taken full face without hat, and the photographs
inchi 2 ½ kwa inchi 2 upana wala usipungue inchi 2 kwa inchi 1 ½ . must not be mounted. The size of the face must not be more than 2 ½
Ni lazima picha hizi ziwe katika karatasi nyembamba ya kawaida inches by 2 inches or less than 2 inches by 1 ½ inches. The
ya picha na wala isiwe inang’ara. Kwa upande wa nyuma wa picha photographs must be printed on normal thin photographic paper and
moja, anayependekeza aandike maneneo yafuatayo: Ninathibitisha must not be glazed. The recommender is supposed to endorse on the
kwamba picha hii ni sura hasa ya muombaji passpoti, Bw./Bi./Bint. reverse side of one copy of the photograph with the words:” I certify
......... Na atie sahihi yake. that this is a true likeness of the applicant Mr. /Mrs. / Ms ....... and add
4. Ada hivi sasa ya paspoti ya kurasa 34 ni KES. 7,500, kurasa 50 his/her signature.
ni KES.9,500, kurasa 66 ni KES. 12,500, Diplomatic ni KES. 15,000 , 4. The current fee for a 34 page passport is Sh. 7,500, 50 page
paspoti ili-yopotea ni KES. 20,000, paspoti iliyoharibiwa ni passport is Sh.9,500, 66 page passport is Sh.12,500, Diplomatic Sh.
KES.20,000. 15,000, Lost passport Sh. 20,000, Mutilated passport Sh. 20,000
5. Fomu ya maombi ipelekwe na mwenye kuomba binafsi katika 5. Application for a passport must be submitted personally by the
Ofisi kuu yapaspoti, Nyayo House, Nairobi, Mombasa (Uhuru na applicant to the Passport Control Office, Nyayo House, Nairobi, or to
Kazi Building), Kisumu (Reinsurance Plaza), au Eldoret (Public the Branch Passport Control Offices,:- Uhuru Na Kazi Building,
Works), Garissa, Nakuru(Ofisi ys PC), Embu( Ofisi ya PC) katika Mombasa, New PC’s Office Kisumu, Public Works Building, El- doret,
muda usiopungua siku 20 kabla ya tarehe ya kusafiri. Garissa, Nakuru PC’s office and Embu PC’s office at least 20 days
6. Paspoti haiwezi kutolewa au kuongezwa muda wake hapa nchini before the scheduled date of travel.
kwa niaba ya mtu ambaye tayari yuko nje ya Kenya. Mtu huyo 6. A passport cannot be issued or renewed by a Passport Control
anapaswa kuwasilisha ombi lake kwenye ofisi ya ubalozi wa Kenya officer on behalf of a person already abroad. Such persons should
uliyo karibui naye, na katika nchi ambako Kenya haina uwakilishi apply to the nearest Kenya Mission abroad or, where there is no
wa kibalozi, katika ofisi ya ubalozi wa Uingereza iliyo karibu naye. Kenya repre- sentative, to the nearest United Kingdom Mission.
Paspoti hazitumwi nje ya Kenya kwa njia ya Posta. Passports are not sent out of Kenya by post.
7. Hati za kuonyesha ni raia wa Kenya ni lazima zitolewe. 7. Documentary evidence of Kenya citizenship must be produced.
8. Fomu zote za maombi ya paspoti ziambatanishwe na paspoti ya 8. All applications must be accompanied by a previous passport, if
awali kama ipo, Kitambulisho cha Kenya aina ya kisasa, cheti cha any or current national Kenya Identity Card, Birth Certificates plus
ku- zaliwa na kopi za kila moja ya hati hizi ambazo zimethibitishwa. certi- fied photocopies of each.
9. Habari zote zitakazotolewa zitahifadhiwa kama siri ya serikali na 9. Information will be treated confidentially and shall not be passed to
hazitajulishwa mtu yeyote asiyestahili. any unauthorized persons.
10. Utajulishwa kuhusu maombi yako kwa njia ya ujumbe mfupi na 10. You will then receive notifications on the progress of your
barua pepe. application via sms and email.
Majina Kamili / Full Names JAMES BUSIENEI, YABAN
Mahali pa kuzaliwa Tarehe ya Kuzaliwa Maelezo ju ya muombaji
Place of birth: NAROK Date of Birth: 1957-01-01 Description of applicant MALE
Nambari ya Kodi Nambari Ya Kitambulisho
Personal Identification Number: A002117558S National ID Number 4669447
Iwapo jina limebadilishwa kwa sababu nyingine mbali na ya ndoa, Nchi unayoishi
andika jina lako la zamani Country of residence KE
If name has been changed other than by marriage, state original name:
Profession/Occupation
Anwani ya posta Kazi BUSINESS MAN
Postal Address:18
Kimo
Nambari ya simu / Tel. No.: Height 5FT:8INS
Mahali unapoishi/Residential address: Rangi ya Macho
a) Eneo la Makazi au Mtaa/Estate /Sublocation: MIHANG'O Colour of eyes BLACK
b) Nambari ya Ploti/Plot No/ Hse. No./ Kijiji/ Village Alama isiyo ya kawaida:
CAPITAL HILL Special peculiarities: NONE
c) Nambari ya simu ya Nyumbani a) Majina Kamili ya Baba
Home Tel No: 254728151222 Father’s Full Name: JOHN KIPYABAN KALIASOI
d) Barua Pepe Nambari ya Kitambulisho
Email address: JAMESBUSIENEI100@GMAIL.COM Identity Card No. :
e) Simu ya Mkono Nambari ya Paspoti (au Rno.)
Mobile phone Number: +254728151222 Passport No. (or Rno.):
b) Mahali Baba alipozaliwa
(2) Mwananchi wa Kenya kwa: Place of Father’s birth:
Citizen by:BIRTH c) S L P P.O. Box:
If by Registration or by Naturalization d) Nambari ya Simu/Tel:
Nambari ya Hati/Certificate No. 2900459 a) Majina Kamili ya Mama
Tarehe ya Kutolewa/Date of issue Mother’s Full Name : SARAH TAPLETGOI
(3) Hali ya Ndoa/Marital Status: MOSONIK
MARRIED Nambari ya Kitambulisho
Majina kamili ya mke/mume Identity Card No. :
Spouse’s full names: CECILIA KERUBO BUSIENEI Nambari ya Paspoti (au Rno.)
Passport No. (or Rno.):
Jina la usichana(pale inapohusu)
b) Mahali Mama alipozaliwa
Maiden name
Place of Mother’s birth: :
Tarehe na mahali pa kuoa/kuolewa c) S L P P.O. Box :
Date and place of marriage , NAROK d) Nambari ya Simu/Tel:
(4) Sababu ya kusafiri
Reason for travel VISIT
(5) Watu wa kupashwa habari dharura jambo linapotokea
Particulars of Next of Kin (Persons who may be contacted in case of emergency)

a) Majina Kamili Full Names CECILIA KERUBO YABAN Tarafa/ Division ILMOTIOK Kata/ Location SOGOO
Uhusiano naye/Relationship WIFE
Nambari ya Kitambulisho chake /ID No 10628637
S.L. P/P.O Box 18 Tel 254725264626E-Mail CECILIAKERUBO100@GMAIL.COM
b) Majina Kamili Full Names LUCY MORAA MARANGA Tarafa/ Division MASABA Kata/ Location NYARIBARI MASABA
Uhusiano naye/Relationship SISTER
Nambari ya Kitambulisho chake /ID No 10660954
S.L. P/P.O Box 18 Tel 254726970655 E-Mail LUCYMORAA100@GMAIL.COM
(6) Watoto Wako
Particulars of legitimate /legally adopted child /children

Majina Kamili Mahali pa Kuzaliwa Tarehe ya kuzaliwa Jinsia

Full Names Place of Birth Date of Birth Gender

(7) MDHAMINI (Tazama maelezo ya kujaza nambari 2, 3 na 11)

Natoa uhakikisho kwamba anaeomba pasporti ni mtu ninaemfahamu binafsi na kwamba naamini maelezo alioandika
hapa ni ya kweli. Mimi ni mwananchi wa Kenya
RECOMMENDER (refer to notes no.s 2, 3 and 11)
I certify that the applicant is personally known to me, and that to the best of my knowledge/ belief the facts stated in
this form are correct. I am a citizen of Kenya
Majina Kamili Nambari ya Kitambulisho
Full Names:.... ID No. (Attach certified copy):
Kazi
Email:
Profession/Occupation:
Anwani
Telephone
Address P.O. Box:...........
Sahihi Tarehe

Signature: ............................................................... Date .....................................................................

(8) UAMUZI Mimi niliyetia sahihi yangu hapa naomba nipewe paspoti. Naidhinisha
(a) Kwamba maelezo yaliyotolewa katika fomu hii ya maombi ni ya kweli nijuavyo mimi mwenyewe na kuamini.
(b) Kwamba sijapata uraia wa nchi nyingine.
(c) Kwamba sijawahi kuwa na, au kuomba paspoti yoyote au.
(d) Kwamba pasi zote nilizopewa nimerudisha isipokuwa paspoti au cheti cha kusafiri No:

............................................................................................... ambayo / ambacho kiko pamoja na fomu hii ya maombi,

tena sijapeleka maombi mengine ya pasi tangu nipewe paspoti au cheti hiki cha kusafiri
(Futa kwenye mstari "C" au "D" yale yasiyokuhusu)
I declare
(a) That the information given in this application is correct to the best of my knowledge and belief.
(b) That I have not acquired citizenship of another country
(c) That I have not previously held or applied for a passport of any description.
(d) That all previous passports granted to me have been surrender other than passport or travel document No

................................., which is now attached, and that I have made no other application for a passport or travel
document was issued to me.
(e) I (Emigrant/ Parent/ Gurdian)

.......................................................... ......of P.O. Box......................................................... and ID Number

..................................................... hereby agree to bind myself to pay the gorvernment any charges and expenses
(including expenses of repatriation from oversees of the Emigrant and Dependants, if any) which may be incurred by
the Government fo Kenya in respect of myself.
(Delete "C" or "D" whichever is inapplicable")
Sahihi Signature (Applicant) Tarehe Date:

............................................................... .......................................................................
FOR OFFICIAL USE ONLY

Applicant's Birth Father's/Mother's Birth Grandparent's Birth Child(ren)'s Birth

Marriage Certificate Other Documents
Certificate and ID Certificate Certificate Certificate

CATEGORY OF PASSPORT TO BE ISSUED

ORDINARY,,RENEWAL,34

PHOTOGRAPH Applicant’s ID No_________________________________________________________

Verified By_______________________________________________________________

Passport No______________________________________________________________

Issued on ________________________________________________________________

Serial No ________________________________________________________________
REMARKS

Recommending officer: Approving officer: Issuing officer

Name: ____________________________ Name: ____________________________ Name: ____________________________

Signature: _______________________ Signature ________________________ Signature: _______________________

Date: ____________________________ Date ____________________________ Date: ____________________________