This form must be sent with the rest of your material (shipping information below).
All questions MUST be answered and this 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: ____________________________  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 search 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:
Passport & Visa Exchange Service Fee
(for express service: 4 days to 3 weeks - $145.00)
(for standard service: approximately 3 weeks - $95.00)
for 1 to 3 day service click for our Super Rush option)		               $____________
Federal Express Return Ship (per address) - $26.00  $__________________
Federal Express Saturday Delivery - (add $15.00) $__________________
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.
 
NOTE: For reliable service,
send via FedEx ONLY.
Ship Package To: -->

Passport & Visa Exchange
50 S. Pickett Street ~~ Suite 212
Alexandria, VA 22304
1-800-767-VISA (8472)