1. Be sure to have completed the steps to have your document(s) notarized and certified as laid out in our Document Legalization Instruction Page.
  2. PRINT, complete and sign this form and include it with the documents to be legalized.
  3. Ship IMMEDIATELY to the address listed on the bottom of this form.

All questions MUST be answered. The form MUST be SIGNED.
Call us at 1-800-767-8472 or 703-739-0974 with any questions you may have.

Traveler Information:
Name: ________________________________________________________________________
Address: ________________________________________________________________________
City, St, Zip: ________________________________________________________________________
Email Address: ____________________________  Day Phone: ________________________
Place of Birth:
(City, State, Country)
____________________________  Night Phone: ________________________
Sex: ______ Date of Birth: ______________________  Fax: ________________________
Shipping Information (If same as above, leave blank):
Name: _______________________________________________________________________
Company: _______________________________________________________________________
Address: _______________________________________________________________________
City, St, Zip: _______________________________________________________________________
Email Address: _______________________________________________________________________
Day Phone: ____________________________ Night Phone: ________________________
Other Phone: ____________________________ Fax Number: ________________________
Document Information:
Country / Number of Documents Date Needed
Any Other Comments:
Payment Information:
State Department Fee                  $12.00
Service Fee                  $49.00
Total Remitted:     $_____________
Payment Method:     Visa    MasterCard    Amex    Money Order    Business Check    Cashiers Check
Card Number:
   3 digit code:
   Exp. Date:
Name of Cardholder: __________________________ Signature: ____________________________________
Cardholder acknowledges receipt of services in amount of total shown herein & agrees to perform obligation set forth in card members agreement with issuer. Cardholder further acknowledges that in the event that his package does not arrive on time, this fee is nonchangeable and nonrefundable.
Send the completed form
along with your notarized
and certified documents
ASAP to: --->
Passport & Visa Exchange
12771 Gazebo Court
Woodridge, Va. 22192

phone: 703-739-0974 (1-800-767-8472)