Date : __________________

Child's Full Name : _________________________________

Child's Date of Birth : _______________________________

Child's Place of Birth : _______________________________

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

Under the provision of the Privacy Act of 1974 (Public Law 93-579). No information may be release from U.S. government files without the prior written consent of the individual in question. Consequently, an employee of the U.S. Passport Agency cannot discuss the details of your passport application with the courier service without your permission.

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 identified 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 for pick-up.

Signature of Biological Parent/Guardian 

________________________