US Vital Documents Order Form Fax this form to: 512-331-8230 USPassportBureau.com Phone: 512-331-8222 Fax: 512-331-8230 Please fax this form to us after contacting our office for information. Your request must be sent FedEx to one of the following locations.
Name(s) on Passport/application(s):______________________________ Last 4 digits of your Social Security:__________ Please circle the type of passport you are applying for: New Passport Renewal Child Passport Lost or Stolen Name Change Extra pages You must provide your own prepaid FedEx Labels and envelopes. You can not send your package using any other mail courier. Please provide the FedEx tracking numbers below. FedEx tracking number going to US Vital Documents: ______________________ (you may call us with this information) FedEx tracking number going back to you:__________________________ (you may call us with this information) Phone Numbers: Work:_____________ Home:______________ Other:_____________ Date of birth(s): ______________ _____________ Email Address: ___________________________ Date of departure from the US:_______________ Time of Departure:__________ Date your package will arrive in opur office (if you over night it today put tomorrows date):______________ Letter of Authorization used? (circle one) Chicago Washington Philadelphia Payment information (Checks are not accepted) US Vital Documents Fees Per Person(UVD fee)
US Government Fees Per Person
Payment Information (please fill in)
Please note: Passports are processed according to departure dates. You must call to reserve a space due to the limited amount of appointments issued to us by the state department. Our service fee ( UVD fee) is non refundable if your reservation is not cancelled 48 hours ( 2 business days) in advance. Credit Card Number _________________________ Exp____________ Credit Card Billing Address:
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City__________State______Zip________
Signature:__________________________
we accept Visa , Master Card, American Express, and discover.
US Vital Documents or any of its agents are not responsible for mistakes or delays from passport offices, consulates, embassies travel agents, overnight courier services, or vital records departments. I understand that the passport office or above agencies can delay or deny passports, visas or birth certificates. U.S Vital Documents will not be held liable for any financial loss occurred by any delay in the process. There is a $25 fee for all canceled requests if canceled 48 hours in advance. If you do not cancel your request 48 hours in advance our service fee (UVD fee) is not refundable. . By submitting this application, you agree to these terms.
Please initial our check list
1. Letter of Authorization ( 2 copies )______
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