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 with any questions you may have.
Traveler Information:
Name: _______________________________________________________________________
Address: _______________________________________________________________________
City, St, Zip: _______________________________________________________________________
Departure Date: ________       Destination: ______________  Phone: ________________________
What is the name and/or email address of your travel agent? (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
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)
Passport & Visa Exchange Service Fee  
(for 1-2 business days service - $299.00) 
(for 3-5 business days service - $199.00) 
(for 6 or more business days service - $125.00) 
Federal Express Return Ship (per address) - $29.00                $_________
Federal Express Saturday Delivery - (add $20.00)                $_________
If, for any reason, the Passport Office suspends your passport, a reprocessing fee will be charged.
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.
Ship Package To: -->

Passport & Visa Exchange
12771 Gazebo Court
Woodbridge, VA. 22192

1-800-767-8472 (VISA)