U.S. Department of State Philadelphia Office
Date _______________________
I ______________________________________ authorize Speedy Passport & Visa
to submit my passport application to a U.S. Passport Agency and accept the delivery
on my behalf.
Please choose one of the following:
____ I authorize Speedy Passport & Visa to discuss any problems that which may arise
with my passport application.
____ I want the U.S. Passport Agency to contact me directly should a problem arise
with my passport application.
____________________________ Applicants name:
____________________________ Date of Birth:
____________________________ Departure Date
____________________________ Destination
____________________________ Applicants Signature _________________ Date
____________________________ Parents signature __________________ Date (if applicant is under 16)
____________________________ Contact number