SPECIAL SUPER RUSH RESERVATION FORM

If you require SUPER RUSH service (1-3 days) you MUST follow these instructions.

  1. Call us immediately to receive your reservation slot.
  2. PRINT, complete and sign this form and include it with the rest of your application material.
  3. FEDEX your package 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: ________________________________________________________________________
I am reserving a slot for super rush passport service for ___________ (date). I understand that this is non-cancellable and non-refundable.
Address: ________________________________________________________________________
City, St, Zip: ________________________________________________________________________
Email Address: ____________________________  SS Number: ________________________
Place of Birth:
(City, State, Country)		 ____________________________  Day Phone ________________________
Sex: ______ Date of Birth: ______________________  Night Phone: ________________________
Departure Date: ________       Destination: ______________  Other Phone: ________________________
Todays Date: __________       Length of Trip: ____________  Fax Number: ________________________
Height: _______________        Hair Color: ___________________ Eye Color: ________________________
Have you ever been issued a US passport? _______ If yes, name on passport: _______________________
Date of Issue: _________________ Most recent US passport number: ________________
Current/Last Passport: Submitted     Lost     Stolen     Other: ___________
Other names you've used in the past: _________________________________________
Spouse Information:
Have you ever been married?: ____________    If yes, Spouse's (or former spouse) Full Name: _________________________
Date of Marriage: ________________    Spouse Date of Birth: _______________    Spouse Place of Birth: _______________
Is spouse (or former) a US citizen?: ___________    Is spouse (or former) widowed or divorced: _______________   
Parent Information:
Mother's Maiden Name - Last: ________________ First: ________________ Middle: ________________
Date of Birth: _______________ Place of Birth: ________________ US Citizen? _____
Father's Full Name -       Last: ________________ First: ________________ Middle: ________________
Date of Birth: _______________ Place of Birth: ________________ US Citizen? _____

Emergency Contact:
Name: _____________________________ Address: _________________________
Telephone(s): _____________________________ Relationship: _________________________

Optional Questions: (help us serve you better)
Why did you choose us for processing your passport needs? (optional)
_____________________________________________________________________________________________________
What is the name and/or email address of your travel agent? (optional)
Most importantly. how did you find us? If online, what serach engine or link? If offline, where did you learn of us? (optional)
_____________________________________________________________________________________________________
Shipping Information (If same as above, leave blank):
Name: _______________________________________________________________________
Company: _______________________________________________________________________
Address: _______________________________________________________________________
City, St, Zip: _______________________________________________________________________
Email Address: _______________________________________________________________________
Day Phone: ____________________________ Night Phone: ________________________
Other Phone: ____________________________ Fax Number: ________________________
Passport Service Type:


New Adult Passport
New Children's Passport
Renew Passport		 Add Pages to Valid Passport
Replace Lost or Stolen Passport
Name Change on Valid Passport
Extend Limited Validity Passport
Payment Information: (this is our fee and must be included - any state dep't fees are separate)
Super Rush Passport & Visa Exchange Service Fee (nonrefundable)                $195.00
Federal Express Return Ship (per address) - $28.00  $__________________
Federal Express Saturday Delivery - (add $18.00)  $__________________
If, for any reason, the Passport Office suspends your passport, a reprocessing fee will be charged.
Total Remitted:  $__________________
Payment Method:     Visa    MasterCard    Money Order    Business Check    Cashiers Check
Card Number:
                               
     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 your packet ASAP via
priority FedEx to: --->
 Passport & Visa Exchange
50 S. Pickett Street ~~ Suite 212
Alexandria, Va. 22304
phone: 703-739-0974 (1-800-767-8472)