| 460 Van Emburgh Ave, Ridgewood, New Jersey 07450 USA Tel: (201) 445-7088 Fax: (201) 445-0588 Email: service@visarite.com Web: www.visarite.com |
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| NAME: | |||||||||||||||||
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First Middle) |
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| DATE OF BIRTH: | |||||||||||||||||
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| SOCIAL SECURITY: | |||||||||||||||||
| I authorize VisaRite Services Inc. to submit my passport application to US Passport Agency and to collect it when issued on my behalf. | |||||||||||||||||
| I authorize the US Passport Agency to discuss any problems which may arise with my passport application with VisaRite Services Inc. | |||||||||||||||||
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