This form must be sent with the rest of your material (shipping information below).
All questions MUST be answered and this form MUST be SIGNED.
Call us at 1-800-767-8472 or 703-739-0974 with any questions you may have.
Traveler Information:
Name: _______________________________________________________________________
Address: _______________________________________________________________________
City, St, Zip: _______________________________________________________________________
Departure Date: ________       Destination: ______________  Phone: ________________________
What is the name and/or email address of your travel agent? (optional)
Shipping Information (If same as above, leave blank):
Name: _______________________________________________________________________
Company: _______________________________________________________________________
Address: _______________________________________________________________________
City, St, Zip: _______________________________________________________________________
Email Address: _______________________________________________________________________
Day Phone: ____________________________ Night Phone: ________________________
Other Phone: ____________________________ Fax Number: ________________________
Passport Service Type:


New Adult Passport
New Children's Passport
Renew Passport		 Add Pages to Valid Passport
Replace Lost or Stolen Passport
Name Change on Valid Passport
Extend Limited Validity Passport
Payment Information: (this is our fee and must be included - any state dep't fees are separate)
Passport & Visa Exchange Service Fee  
(for 24 hour service - $199.00) 
(for super rush service - 2 to 6 business days - $179.00) 
(for rush service: 7 to 10 business days - $149.00) 
(for extended service: beyond 10 business days - $99.00)  		              $_________
Federal Express Return Ship (per address) - $29.00                $_________
Federal Express Saturday Delivery - (add $20.00)                $_________
                
If, for any reason, the Passport Office suspends your passport, a reprocessing fee will be charged.
Total Remitted:                $_________
Payment Method:     Visa    MasterCard    Amex    Money Order    Business Check    Cashiers Check
Card Number:
                               
    3 digit code:
     
    Exp. Date:
       
Name of Cardholder: _____________________________ Signature: ___________________________________
Cardholder acknowledges receipt of services in amount of total shown herein & agrees to perform obligation set forth in card members agreement with issuer.
 
Ship Package To: -->

Passport & Visa Exchange
2801 Ridge Road Drive
Alexandria, Va. 22302
1-800-767-VISA (8472)