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 - Passports

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

Service Requested

Please check one of the following:

Payment Information

For Government:

Check or Money Order

Government Fee: Payable to US Department of State       
(Please include Date of Birth on Check)

$______________

NOTE: Please include this payment SEPARATELY from the Passport Depot fee below.

For Passport Depot:

Money order or Business check
Credit Card

Passport Depot Fee: Payable to Passport Depot                 $_______________

                                 Shipping:                                           $_______________

                                 Total:                                                $_______________



If Paying by Credit Card

Payment Type:

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.