Toll Free: 800-689-1388 / Toll Fax: 800-687-1388        Phone: 415-437-1388
Email: info@passportdepot.com       http://www.passportdepot.com

 

Customer Information Form - VISA


Applicant’s Full Name: _______________________________________________________________________

Applicant’s Date of Birth: _____________________________________________________________________

Company Name (if applicable): ________________________________________________________________

Address: __________________________________________________________________________________

City: _____________________________________________________________________________________

State: _________________________________ Zip: ____________________________

Home Phone: _________________________________________________________________

Mobile Phone: _________________________________________________________________

Work Phone: __________________________________________________________________

E-Mail Address: _______________________________________


Shipping Information (If Different From Above)

Name: ____________________________________________________________________________________

Address: __________________________________________________________________________________

City: _____________________________________________________________________________________

State: _________________________________ Zip: ____________________________

Home Phone: _________________________________________________________________



Travel Information

U.S. Departure Date: ________________________________

Traveling To: ______________________________________


Indicate Proof of Departure included:

1) Copy of Plane Ticket or Itinerary
2) Business Letter


Return Shipping of Passport

 
Overnight delivery (add $18.00)
 
Saturday Delivery (add $32.00)*
  *(Sat. Delivery not available in all zip codes, check with FedEx)


Service Requested

 
Rush Service Fee ($89.00)
 
Regular Service Fee ($59.00)


Payment Information

Visa Service Fees (ONLY APPLICABLE FOR CERTAIN COUNTRIES)

Money order - $________________

NOTE: Please include Consular Fees with Passport Depot Fees payment TOGETHER.


For Passport Depot:

Money order or Business check
Credit Card

Passport Depot Fee:       Payable to Passport Depot                      $_______________

                                       Consular Fees (varies):                            $_______________

                                       Shipping:                                                $_______________

                                       Total:                                                     $_______________



If Paying by Credit Card

Payment Type:

 
Visa
 
MasterCard
 
Discover
 
American Express

Credit Card Number: __ __ __ __ - __ __ __ __ - __ __ __ __ - __ __ __ __

Expiration: _____ / _____



Billing Information

Address: ______________________________________________________________________

City: _________________________________________________________________________

State: _________________________________ Zip: ____________________________

 

FedEx Information

FedEx Tracking Number: _____________________________________________________________

Date Sent: _________________________________________________________________________





I authorize Passport Depot to charge the TOTAL AMOUNT DUE to my credit card.



Signature: ____________________________________________________________________

Date: ________________________________

 

Upon completion of this form and signing it, please PRINT this document by clicking
CTRL+P or the by clicking on the printer icon and mail directly to:


PASSPORT DEPOT
Toll Free: 800-689-1388 / Toll Free Fax: 800-687-1388
Phone: 415-437-1388


All information is kept strictly confidential and will not be shared or sold to any third party agency in accordance
with the laws and regulations stated on Passport Depot’s Privacy Policy.