Requirements To Expedite Replacement Of Lost U.s. Passport Form (Page 6 of 9) in pdf

Requirements To Expedite Replacement Of Lost U.s. Passport Form Page 6

Pinnacle Travel Document Systems

1625 K Street NW Suite 750

Washington DC 20006

888-838-4867

Letter of Authorization

Please carefully read the information below before completing this Letter of Authorization.

An individual’s personal information cannot be released by the U.S. government to another party without

(5 USC

552a). As a

the written consent of the individual under the provisions of the Privacy Act of 1974

result, an employee at a U.S. passport agency cannot discuss the details of your passport application with

a third party without your written consent.

Please check all that apply:

I authorize the company stated below to submit my passport application to a passport agency and

pick up the passport from a U.S. passport agency on my behalf.

I authorize the passport agency to disclose to the company listed below any requests for further

documentation and/or information that that may arise in connection with my passport application,

and I authorize the company to respond to such requests under my direction.

I do not authorize the passport agency to disclose to the company listed below any requests for

further documentation and/or information that may arise with my passport application. I want the

passport agency to contact me directly should an issue arise with my passport application that

concerns matters other than the date on which the passport will be ready for pick-up from the

passport agency.

Applicant Information

(Note: All of the information below may ONLY be filled out by the applicant, parent, legal

guardian, or person legally acting in loco parentis)

Applicant Name: ____________________________________________________________________

(Last Name, First Name, Middle Name)

Applicant Phone No: _____________________________

Date: ____________________

(Area Code-XXX-XXXX)

(MM/DD/YYYY)

Courier Company Name: ___________________________________________________________

Applicant Signature: __________________________________________________________________

(If the applicant is under the age of 16 the parent(s),legal guardian(s), or person legally acting in loco

parentis must sign)

Requirements To Expedite Replacement Of Lost U.s. Passport Form Page 6