| 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 |
||
| NAME: | ||||||||||||||
(
First Middle Last) |
||||||||||||||
| DATE OF BIRTH: | ||||||||||||||
(Month
/ Day / Year) |
||||||||||||||
| CONTACT PHONE : | ||||||||||||||
| 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. | ||||||||||||||
|
||||||||||||||