2600 South Gessner Rd., Suite 200 Houston, Texas 77063

Specializing in Rush Passports, Visas for all Countries, and Certified Birth Certificates

Phone: (713) 629-8330	Fax: (713) 785-1461
http://www.quickpassport.com	email: info@quickpassport.com

LOST/ STOLEN PASSPORT ORDER FORM

Print this form, fill it out and send it to us with your information after going to your local acceptance agent.
DO NOT PUT THIS FORM IN THE GOVERNMENT SEALED ENVELOPE

Name(s) in passport/application(s):_____________________ ____________________________
******Please write the applicant's full name, date of birth and phone number on the sealed envelope********
Maiden Name: _____________________________________________________________________

Shipping address and phone number
for Federal Express Delivery:

Address for Saturday Delivery: ( if needed )

__________________________

______________________________

__________________________

______________________________

Phone:___________________________________E-Mail _______________________

Have Federal Express deliver without a signature? (circle one) YES NO

Phone numbers: Work____________________ Home:_________________ Other:_______________

Date of Birth(s):________________________ _________________________

Date of Departure from the US:_______________Time of Departure_____________________
Social Security numbers of applicants (this is required when we have to discuss your application with
the passport agency). SS#____________________________ ________________________________

Payment Information:
Governments fee	$_______________
PVS Fee*	$109 or **$169 see below
Return Delivery Fee	$25.00
Total	$_________________

US Goverment Fees (per person)
New / Lost Passport (in sealed envelope)	$170 Adult $140 Child
Renewal	$170
Extra Pages	$60
Name Change	$142
Passport Card	$30

Usbirthcertificate.com/PVS processed my birth certificate (no service fees needed above). If you have our Sales Receipt number
we emailed to you please write it here:_____________________

Credit Card Number: ______________________________ V- Code ( Required)_______Expires:___________	Passport And Visa Specialists Fees Passport Regular Service $109.00 **1-2 Business Day Service $169.00 (You must be leaving the country in 3-4 business days for this service). We must receive your package in our office no later than 8:00am.YOU MUST FAX THIS FORM TO OUR OFFICE FOR NEXT DAY SERVICE BEFORE SHIPPING YOUR PACKAGE TO US.
	Passport Card $35
Signature_________________________	Return Delivery Fee: Federal Express Weekday: $25.00 Federal Express Saturday $40.00 Federal Express First Overnight $65.00 Federal Express Same Day Service $250-$400 *Fedex First Overnight and Same day service are not available to all zip codes.

We accept checks, money orders, cashiers checks,Visa, Mastercard and Discover.
*PVS stands for Passport and Visa Specialists' processing fees. Passport and Visa Specialists 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 at their own discretion. PVS is not responsible for these delays