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
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.
(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: ___________________
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