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
Print this form, fill it out and send it to us with your information after going to your local acceptance agent.

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 (important) _______________________
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:

PVS Fee*
$109 or **$169 see below

Return Delivery Fee
US Goverment Fees(per person)
New / Lost Passport
(in sealed envelope)
$170 Adult
$140 Child
Renewal $170
Extra Pages $142
Name Change $60
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:___________
V-code is last 3 numbers in the signature box of your credit card.
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
Return Delivery Fee:
Federal Express Weekday: $30
Federal Express Saturday $45
*Federal Express First Overnight $70
*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.