Replacement Passport Application Form - Urgent Passport Services Page 3
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4URGENT PASSPORT ORDER FORM
THIS ORDER FORM MUST BE FILLED OUT COMPLETELY.
PLEASE FEDEX OR UPS ALL REQUIRED DOCUMENTS
1-800-573-3738
APPLICANT INFORMATION:
URGENT PASSPORT EXPEDITING FEES:
Departure Date
(1) Expedited Service - select one -
Fees:
Amount:
- Sameday Processing
$250
Full Name
$
- 2 Day Processing
$200
Date of Birth
- 3 or 4 Day Processing
$160
Place of Birth
- 6 Day Processing
$125
Last 4 digits of Social Security #
- 10 Day Processing
$80
E-mail
$
(2) Return Shipping Fee:
- select one -
Fees:
- FedEx Standard Overnight
(by mid-afternoon)
$22
CC E-mail
- FedEx Priority Overnight
(by noon)
$27
Home Address
- FedEx Saturday Delivery
(Saturday by 3PM)
$40
- FedEx First Overnight
(by 8:30AM)
$60
City
State
$
Total Urgent Passport Fee: (1 + 2) =
----------->
Zip Code
Phone
SEND MY COMPLETED PASSPORT TO:
CREDIT CARD PAYMENT - CHECK ONE
Address 1
VISA
MASTERCARD
AMEX
Address 2
Name on Card
City
State
Billing Zip Code
Expiration
Zip Code
Cell Phone
Credit Card #
3 or 4 Digit Code
TO ENSURE TIMELY PROCESSING:
Cardholder Signature X
1
PRINT ALL PAPERWORK OFF WEBSITE, READ
INSTRUCTIONS CLOSELY, & GATHER DOCUMENTS
OTHER PAYMENT OPTIONS
MONEY ORDER
CASHIER'S CHECK
2
DS-5504 FORM MUST BE DONE ONLINE & PRINTED
Payable to: URGENT PASSPORT SERVICES
(HANDWRITTEN FORM WILL GET REJECTED)
(Personal Checks Not Accepted for Company Fee)
3
CALL 1-800-573-3738 FOR SHIPPING ADDRESS
SHIPPING INFORMATION: WHEN READY TO SHIP CALL 1-800-573-3738
SHIPPING ADDRESS #1
SHIPPING ADDRESS #2
(FEDEX ONLY)
(FEDEX ONLY)
URGENT PASSPORT
URGENT PASSPORT
230 S. CLARK ST.
4901 S. ZUNI ST.
# 222
(FEDEX HOLD - J. PALSON)
CHICAGO, IL 60604
LITTLETON, CO 80120
* WE WILL ROUTE YOU TO THE SHIPPING ADDRESS THAT PROVIDES THE FASTEST SERVICE *
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