Uk Visa Order Form Passport Visas Express
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1Telephone 312-291-0170
Fax
312-291-0171
Email
Website
UK VISA ORDER FORM
Applicant Name(s): _______________________________________________________
U.S. Departure Date: ______________________________________________________
Contact Telephone/Fax: ____________________________________________________
Contact Email: ___________________________________________________________
SHIPPING ADDRESS
Passport Visas uses Federal Express to return your travel documents. We cannot ship to a Post Office Box. If you would like to send a
prepaid return envelope we will be happy to return your documents as indicated.
Name: ____________________________________
Street Address: ____________________________________
Apartment/Suite #: ____________________________________
City and State: ____________________________________
Zip Code: ____________________________________
Telephone: ____________________________________
FEES
Service Requested:
Service Fee:
Please indicate:
Rush Service
$125.00
(You must call to arrange this service)
2-3 Business Days - express
$100.00
4-5 Business Days - regular
$85.00
Other (service surcharge to BCG $150.00), etc
FedEx Return Delivery (optional):
_____$25.00______
Total: ________________
PAYMENT METHOD
By check or money order: Please make fees payable by to Passport Visas
Credit card:
Visa MasterCard - only those two will be acceptable
Card Number: ___________________________________________________
Exp. Date: ______________________________________________________
Cvv2 code (from the back of the card) _______________________________
Your Name as it Appears on Card: ________________________________
Full Billing Address:
__________________________
(mark if same as shipping address)
________________________________________________________________
Cardholder Signature: _____________________________________________
Cardholder acknowledges receipt of goods and/or services in the amount of the Total shown hereon and agrees to perform the
obligations set forth in the Cardholder's agreement with the issuer.
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