Debit/credit Card Payment Form For Passport Issuance Fees - United States Embassy London
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1UNITED STATES EMBASSY - LONDON
Debit/Credit Card Payment Form for Passport Issuance Fees
Please fully complete all items and sign. Before submitting the form with your application,
notify your credit card company, otherwise the payment may be declined.
DEBIT/CREDIT CARD:
DINER’S
AMERICAN
(PLEASE TICK
MASTERCARD
VISA
DISCOVER
EXPRESS
CLUB
APPROPRIATE BOX)
OTHER DEBIT CARDS AND CREDIT CARDS CANNOT BE ACCEPTED
ISSUING BANK (i.e. Barclays, Bank of
America, HSBC, Wells Fargo, etc.)
:
CREDIT CARD NUMBER
EXPIRATION DATE (MONTH/YEAR):
Month
Year
CALCULATION OF AMOUNT TO BE CHARGED:
ADULT PASSPORT RENEWAL: $110.00
HOW MANY?
TOTAL:
ADULT PASSPORT CARD:
$30.00
HOW MANY?
TOTAL:
TOTAL AMOUNT:
NOTE: The Embassy does NOT offer expedited processing.
EXACT AMOUNT IN U.S. DOLLARS
TO BE CHARGED TO DEBIT/CREDIT
CARD
(in figures)
(in words)
PLEASE NOTE THAT PASSPORT FEES WILL BE CHARGED IN DOLLARS TO YOUR DEBIT/CREDIT CARD, AND
THE POUND EQUIVALENT WILL DEPEND ON THE CARD ISSUER’S EXCHANGE RATE.
NAME AS SHOWN ON
DEBIT/CREDIT CARD (PRINT)
I AUTHORIZE THE U.S. EMBASSY TO CHARGE MY DEBIT/CREDIT CARD FOR THE ABOVE AMOUNT FOR U.S.
PASSPORTS FOR (LIST NAMES OF PASSPORT APPLICANT(S)):
SIGNATURE OF CARDHOLDER:
The information in this form is valid as of the date the form was updated. For the most up-to-date guidance, please see our website on
uk.usembassy.gov
Revised 30 March 2017
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Parent category: Financial