Lost Passport Guide And Forms Page 8
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8Toll-free: (866) 378-1722
Call us for assistance –
Local: ((202) 684 7150Fax: (866) 511-7599
1802 Vernon Street NW, Washington, DC 20009
Email:
TRAVELER(S) INFORMATION:
REFERRED BY:
.
Date of your international trip:
____ / _____ / ______
mm
dd
yyyy
Traveler #1 Name:__________________________
Traveler #3 Name:__________________________
First
Last
First
Last
Traveler #2 Name:__________________________
Traveler #4 Name:__________________________
First
Last
First
Last
RETURN DOCUMENTS TO THIS ADDRESS:
Contact Name:________________________________________ Company: ___________________________
Address: ____________________________________ City: ________________ State: _____ Zip: ________
NO P.O. BOXES
□
□
YES
NO
E-mail: _____________________________________ Signature Required for Delivery?
Phone: _(_____)______________ Cell: _(_____)__________________Fax: _(_____)_________________
Shipping Method :
+ $0
+ $39 FedEx Standard Overnight
(will include my own postage)
+ $15 FedEx Express Saver
to states of HI, AK, or PR
+ $20 FedEx Standard Overnight
+ $39 SATURDAY FedEx Overnight
+ $25 FedEx Priority Overnight
from $39 for International FedEx
+
GOVERNMENT SERVICE:
Select the type of service you request by placing check mark in the appropriate box
st
nd
New 1
Time Passport
2
U.S. Passport
Passport Renewal
Passport for Child
Lost/Damaged Passport
Lost/Damaged Passport for Child
Add Pages
Name Change
SERVICES REQUESTED:
Select the type of service you request by placing check mark in the appropriate box
+ $199 EMERGENCY (Same-Day)
+ $69 RUSH (4 Days)
+ $129 URGENT (2 Days)
+ $39 BUDGET (up to 2 weeks)
□
+
PLEASE ADD FREE PASSPORT REPLACEMENT COVERAGE FOR $9.99. By checking this box, I agree to enroll into passport
replacement program. I authorize Travel Visa Pro to add $9.99 charge per person to other fees paid. I have read and understood all terms
and conditions of the program which are posted at ,do.index.
$
PAYMENT METHOD FOR APPLICABLE FEES
:
please add all fees and enter total HERE:
______________
□
□
□
□
PAID BY
Credit Card
Money Order
PayPal
Check #:
__________
I hereby authorize Travel Visa Pro to charge the cost of its professional visa and passport services to the following card. I agree to pay this
amount to my credit card company and agree to terms and conditions. I understand that requirements, fees, and processing times are
subject to change without prior notice and all fees are non-refundable. An administrative fee of $17 will be added to canceled orders.
Name on Card:__________________________________ Signature:_________________________________
Credit Card #:_____________________________ Expiration Date:
Security Code: ________
________ / _______
mm
yyyy
Billing Address:
Same as Shipping
Other: ____________________________________________________
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