Service Request Form

SERVICE REQUEST FORM

HOW DID YOU HEAR ABOUT US?

RETURNING CLIENT

REFERRAL

INTERNET

YELLOW PAGES

FULL NAME OF APPLICANT:

PHONE (DAYTIME):

PHONE (EVENING):

PHONE (MOBILE):

E-MAIL ADDRESS:

PERSON REQUESTING SERVICE

(IF DIFFERENT FROM APPLICANT):

PHONE (DAYTIME):

PHONE (EVENING):

PHONE (MOBILE):

E-MAIL ADDRESS:

DATE OF DEPARTURE (FROM USA):

/

/

PASSPORT MUST BE IN YOUR POSSESSION BY:

/

/

MONTH

DAY

YEAR

MONTH

DAY

YEAR

RETURN DOCUMENTS:

CALL FOR PICK-UP:

DAYTIME

EVENING

MOBILE

OTHER

SHIP TO (NO P.O. BOXES):

SHIPPING METHOD:

FedEx

(IPV Account)*

FedEx

:

Airbill Enclosed

Other:

®

®

YOUR ACCOUNT

SPECIFY

* IPV Account is FedEx Priority Overnight

unless requested otherwise. (Additional fees apply)

®

NAME:

COMPANY:

PHONE:

STREET:

CITY:

STATE:

ZIP CODE:

PASSPORT SERVICES:

FORM DS-11

FORM DS-82

FORM DS-4085

FORM DS-5504

First Time/Minors/Lost/Stolen/Mutilated

Renewal/Second Passport

Additional Visa Pages

Name Change/Correction/Limited

PROCESSING TIME:

5 WORKING DAYS

48 HOURS

NEXT DAY

SAME DAY

OTHER:

VISA SERVICES:

Country:

Tourist

Business

Work

Student

Transit

Other

Number of Entries

PROCESSING TIME:

REGULAR

EXPRESS

RUSH

ULTRA RUSH

OTHER:

Country:

Tourist

Business

Work

Student

Transit

Other

Number of Entries

PROCESSING TIME:

REGULAR

EXPRESS

RUSH

ULTRA RUSH

OTHER:

METHOD OF PAYMENT:

VISA

MASTERCARD

AMERICAN EXPRESS

CHECK (ONLY CA CHECKS)

MONEY ORDER

2 0

EXPIRATION DATE:

/

CARD NUMBER:

CVV:

MONTH

YEAR

3 OR 4 DIGIT CODE

ON BACK OF CARD

CREDIT CARD BILLING ADDRESS (NO P.O. BOXES):

STREET:

CITY:

STATE:

ZIP CODE:

I,

, authorize EPV to charge the fees for the services provided to my credit card.

PRINT CARDHOLDER’S NAME (AS IT APPEARS ON CREDIT CARD)

CARDHOLDER’S SIGNATURE:

DATE :

/

/

Note: By submitting this form. I authorized Express Passport and Visas to charge the above mention fees. We assume no responsibility for loss, delay or rejection of any document

held by the US government, foreign embassies and consulate, mail and courier services. No refund no cancel orders.