CITIZENSHIP AND PASSPORT APPLICATION
DATE :  
APPLICANT:  
CURRENT  ADDRESS :  
CITY :  
STATE :  
ZIP/POSTCODE :  
COUNTRY :  
TEL.NO :  
FAX .NO :  
PLACE OF BIRTH:  
DATE OF BIRTH:                                                       SEX: 
NATIONALITY:  
COLOR: HAIR:                                           EYES:
DIMENSIONS: WEIGHT:                                     HEIGHT:
PROFESSION:  
OCCUPATION:  
BIRTH NAME:  
NAME OF FATHER:  
NAME OF MOTHER:  
PROFESSIONAL REFERENCE(s) 
(If Applicable) 
 
 
 

 

  
PERSONAL REFERENCE(s) 
 
 
 

 

  
BANK REFERENCE 
(If Applicable)		  

REV 5/00

BRIEF STATEMENT WHY APPLICANT WISHES TO BECOME CITIZEN OF DOM (ATTACH SEPERATE SHEET IF NECESSARY): __________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

APPLICANT DOES ____ DOES NOT ____ REQUIRE DRIVER'S PERMIT

APPLICANT DOES ____ DOES NOT ____ REQUIRE INTERNATIONAL DRIVER'S PERMIT

APPLICANT DOES____ DOES NOT ____ REQUIRE I.D. CARD

FOR EACH PERMIT OR ID CARD PROVIDE AT LEAST TWO PHOTOS HALF THE SIZE OF PASSPORT PHOTOS.


 

ATTESTATION OF UNDERSTANDING AND CERTIFICATION OF INFORMATION.

The applicant understands that the Dominion of Melchizedek can accept no responsibility for the position of any government in regard to DOM passport and/or its other identification documents. The applicant declares that the information on this application is true and correct. Applicant hereby declares that he/she has read the Dominion of Melchizedek Internet WWW site at http://www.melchizedek.com including every link therefrom, especially the press release section including every release found therein.

IMPORTANT: Applicant under 16 years of age must have the Attestation of Understanding signed by a parent or guardian.

I CERTIFY THAT THE FACTS STATED ABOVE TO BE TRUE AND CORRECT TO THE BEST OF MY UNDERSTANDING.

I, THE UNDERSIGNED, HEREBY PROMISE TO LIVE ACCORDING TO THE PRINCIPLES, CONSTITUTION AND LAWS OF THE DOMINION OF MELCHIZEDEK AND HEREBY TENDER MY IRREVOCABLE PROXY FOR THE DOM HOUSE OF ELDERS TO VOTE ON MY BEHALF AT ALL FUTURE DOM ELECTIONS.
 

SIGNATURE:______________________________________DATE:_____________________
 
 

WITNESS:_________________________

 

 

Please send this document to your printer, complete and return with photos and donation, by mail, in person, or by courier.

INCLUDE TWO SMALL PASSPORT PICTURES AND BIRTH CERTIFICATE (IF NOT AVAILABLE, SOME OTHER FORM OF IDENTIFICATION) NOTE:  NOT ALL APPLICATIONS WILL BE ACCEPTED.  IF YOU ARE ALREADY A CITIZEN AND HAVE RECEIVED YOUR DOM PASSPORT, YOU ARE PRELIMINARILY ELIGIBLE TO APPLY FOR A DOMESTIC DRIVER'S LICENSE, AN   INTERNATIONAL DRIVER'S PERMIT AND AN I.D. CARD BY FIRST NOTIFYING VIA E-MAIL ambassador@melchizedek.com AND MENTIONING YOUR NAME AND DOM PASSPORT NUMBER WITH YOUR REQUEST.

RETURN THIS FORM COMPLETED WITH DONATION IN THE AMOUNT OF MONEY THAT YOU CAN AFFORD, (YOUR FINANCIAL HELP IS NEEDED TO BUILD THE DOM), PAYABLE TO THE "DOMINION OF MELCHIZEDEK EMBASSY" (TITHING IS ACCEPTABLE) WITH PHOTOS TO:

Dominion of Melchizedek Embassy-at-Large,  585 Box Canyon Road, Canoga Park, Ca., 91304 (U.S.A.) Tel: 1-818-703-6236 Fax:  1-818-887-3217