Passport No __________
Date __________
To the Secretary of the Interior:
I do hereby swear or affirm that I am 62 years of age or older, that I am a citizen of the United States or that I am domiciled therein and that I am duly entitled to be issued free of charge one Golden Age Passport pursuant to the Land and Water Conservation Fund Act of 1965, 16 U.S.C. A. 460 l-6a (Supp., 1974), as amended by Pub. L. 93-303 .
Signature _______________________________
Street _______________________________
Town, City, State _______________________________
Issuing Officer_______________________________
36 C.F.R. §71.6