Letter Of Authorization Form - A-Passport & Visa Services printable pdf download

Letter Of Authorization Form - A-Passport & Visa Services

A-PASSPORT & VISA SERVICES

P.O.BOX 3626, NEW YORK, NY-10163

Letter of Authorization

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

An individual’s person information cannot be released by the US Government to another party

without the written consent of the individual under the provisions of the Privacy Act of 1974

(5 USC

552a). As a result, an employee at a U.S Passport agency cannot discuss the details of

your passport application with a third party without any written consent.

Please check all that apply:

 I authorized 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 authorized the passport agency to disclose to the company listed below any requests for

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

application, and I authorized the company to respond to such request 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 then the date on which the passport

will be ready for pick-up from the passport agency.

Application Information

(Note: All 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 parents must

sign)

Letter Of Authorization Form - A-Passport & Visa Services