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| 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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| CHILD'S NAME: | ||
(Last,
First Middle) |
||
| CHILD'S DATE OF BIRTH: | ||
(Month
/ Day / Year) |
||
| CONTACT PHONE : | ||
(put
dowm N/A, if not available) |
||
| I authorize VisaRite Services Inc. to submit my child's passport application to US Passport Agency and to collect it when issued | ||
| I authorize the US Passport Agency to discuss any problems which may arise with my child's passport application with VisaRite Services Inc. | ||
| Biological Parent/Guardian Signature: | ||
| Date: | ||
| Relationship (circle one): | Mother
/ Father / Legal Guardian |
|