PASSPORT & VISA SPECIALISTS
4740 Ingersoll St. Suite 207 Houston, Texas 77027
Specializing in Rush Passports, Visas for all Countries, and Certified Birth Certificates
Phone: (713) 629-8330   Fax: (713) 629-0396 
http://www.quickpassport.com email: info@quickpassport.com
ORDER FORM
Print this form, fill it out and send it to us with your information
DO NOT PUT THIS FORM IN THE GOVERNMENT SEALED ENVELOPE

Name(s) in passport/application(s):_____________________    ____________________________


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:_______________

Payment Information ( please fill in)
US Goverment Fee $___________
PVS Fee* $___________
Return Delivery Fee $___________
Total $___________
US Goverment Fees (per person)
New / Lost Passport
(in sealed envelope)
Renewal $115.00
Extra Pages $60.00
Name Change $60.00
PVS processed my birth certificate (no service fees needed above).
Credit Card Number:
______________________________
Passport And Visa Specialists Fees
Passport $89.00
Expires:_________________________
Signature_________________________
Return Delivery Fee:
Federal Express Weekday: $17.00
Federal Express Saturday $27.00
Airport to Airport $150.00
We accept checks, money orders, cashiers checks,Visa, Mastercard, American Express and Discover.

*PVS stands for Passport and Visa Specialists' processing fees. Passport and Visa Specialists or any of its agents our 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 disgression.