Date : __________________

 

I ______________________ authorize an agent of Passports and Visas to submit my passport application to a U.S. Passport Agency and accept delivery of the Passport on my behalf.

Please choose one of the following:

____ I authorize the U.S. Passport Agency to discuss any problems which may arise with my passport application with the courier service above.

____ I want the U.S. Passport Agency to contact me directly should a problem arise with my passport application which concerns letters other than the date on which the passport will be ready to pick-up.

Applicant's Name : _________________________________

Date of Birth : _____________________________________

Place of Birth : _____________________________________

Signature ______________________________