Form 5a - Visa Requirements South Sudan Visa Application Form Page 4

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Send to: G3 Global Services
Attn: Visa Department
WASHINGTON, DC
919 18th Street NW, Suite 230
SOUTH SUDAN
Washington, DC 20006
888.883.8472 |
Your invoice will be sent to your contact email.
Check here if you require a hard copy included with your return delivery.
Payment Information
Check payable to
Enhanced Services Requested:
Payment Via Check #:
G3 Global Services
Document Pre-Check, $59.00
Application Creation, $150.00
Payment Via Credit Card:
Application Correction, $55.00
-
-
-
Visa/MasterCard:
Business Letter Creation, $50.00
Inbound FedEx Airbill, $35.00
Exp. Date: ____ / ____ Security Code:
Return Delivery Confirmation, $15.00
or bundle all services above with our
OR
-
-
American Express:
Complete Concierge Service, $225.00
Exp. Date: ____ / ____ Security Code:
Total Fees from Applicable Fees Page
Please include Applicable Fees page with your request.
Name as it appears on the card:
FEE
# Travelers
TOTAL
Enhanced Service Fee
X
=
Billing Address:
Consular Fee
X
=
G3 Service Fee
X
=
City:
State
Zip:
Passport Protection Plan
X
=
$40.00
Return Delivery Fee
Signature: _________________________________________
Subtotal
Add 5% for credit card convenience fee
Payment Via Approved Billing Terms
G3 Customer Number, Billing, P.O., Project or Reference Code#:
Total Payment Enclosed
Traveler Names
1
3
2
4
Visa Service
Visa Type:
Tourist
Business
Processing Speed:
Mission Critical
Priority
Expedited
Flight Crew
Other__________
Travel Details
Date of US Departure:
I must have my passport no later than:
Other visa or passport services requested:
Notes:
Contact Information
Who should G3 contact about this request?
Name:
Company:
Contact Email (required):
Daytime Phone:
Mobile Phone:
Return Delivery Address
This must be a physical address for FedEx delivery; no P.O. Boxes.
Name:
Company:
Street Address:
City:
State:
Zip Code:
Daytime Phone:
Mobile Phone:

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