Requirements To Expedite Replacement Of Lost U.s. Passport Form (Page 3 of 9) in pdf

Requirements To Expedite Replacement Of Lost U.s. Passport Form Page 3

PLEASE BE CERTAIN TO INCLUDE THE FOLLOWING:

♦

Sealed envelope containing passport application m aterials as noted

♦

This completed form

♦

One (1) photocopy of completed US Government application form DS-11 per person

♦

One (1) PTDS Authorization Letter per person executed in

blue ink

♦

One (1) copy of your flight itinerary or proof of departure from the U.S.

♦

Check or money order payable to Pinnacle TDS or credit card authorization below

LEASE PRINT CLEARLY

Full Name (1):

_____________________________

Full Name (2):

_____________________________

Passport #:

____________________

Exp:

___/___

Passport #:

____________________

Exp:

___/___

M o

Y r

M o

Y r

________________________________

Home

Home Tel:

________________________________

Mailing

Work Tel:

Address:

________________________________

Email:

____________________________________

________________________________

____/____/_____

Date of Departure from Home:

M o n t h

D a y

Y e a r

(Fe dE x ca nno t d eli v er to P O b ox e s )

Address

________________________________

Service: US Passport Lost

________________________________

_____________________

For the

Special Instructions:

________________________________

_________________________________________

Return of

Passport:

________________________________

_________________________________________

Tel:

________________________________

_________________________________________

Pl e a se ind ic a t e b el ow if the r e a re k now n pe ri od s d uri ng w hi ch yo u w ill no t b e a v ai la bl e to si gn for the r etu rn

o f yo u r p a ss po r t vi a F edEx .

_____/____/_____

I w ill no t b e at m y h om e an d/o r r et ur n shi ppi ng ad dre s s from

M o n t h

D a y

Y e a r

M o n t h

D a y

Y e a r

CREDIT CARD AUTHORIZATION:

A M E X / V I S A / M C (please circle one)

Cardholder Name: _ _ __ _ _ __ _ __ _ _ _ __ _ _ __ _ Si g nat u re: _ ___ _ _ _ __ _ _ __ _ _ __ _ _ __ _ Bil lin g Z ip Co d e: __ _ _ __ _ _ __ _ __

Card #: _ _ __ _ _ __ _ _ __ _ _ __ __ _ _ _ __ _ _ __ _ _ _ CI D# _ _ __ _ __ _ _ _ __ _ _

Expires: _ __ _/_ _ _

Amount: US$ __ _ _ __ _ __

M o

Y r

P TDS PSP T (LO S T)89 3 .5%

 2 0 15 Pin na cl e Tr a v el Do cum en t S ys t e m s

Requirements To Expedite Replacement Of Lost U.s. Passport Form Page 3

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