Name(s) in passport/application(s):_____________________    ____________________________

Last 4 digits of your social security__________

You must provide your own prepaid FedEx  labels and envelopes.  You can not send your package using  any other mail courier.    

FedEx  tracking number going to US Vital Documents______________________

FedEx  tracking number coming back to you._________________________________

How did you find our company?___________________________________________

Phone numbers: Work____________________  Home:_________________ Other:_______________

Date of Birth(s):________________________    _________________________

Date of Departure from the US:____________________Email: __________________________

Date your package will arrive in our office:________ Departure Time:____________

Which letter of authorization used? (CIRCLE ONE)

Credit Card Number:
______________________________

Credit Card Billing Address

____________________

________________________

Expires:_________________________
Signature_________________________

We accept money orders, cashiers checks,Visa, Mastercard, 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 request. By submitting this application, you agree to these terms.