1811 Bering Drive Suite #100 Houston TX 77057 Tel - 713-784-5501 Fax – 713-784 -5588

Passport Request Form DATE: ______________________ DATE OF TRAVEL: (NEEDED By) ________________

TRAVELER’S NAME _______________________________ NATIONALITY __________ PHONE # ___________________

DELIVERY ADDRESS__________________________________________________________________________________

TRAVELER’S COMPANY NAME (if applicable) _______________________/ EXECUTIVE ASSISTANT__________________

E-mail _________________________________________ PHONE#_________________________________

Project # (if applicable ______________________________ COST # (if applicable) ______________________________

DISCLAIMER

Sam’s Passport Inc.; will not be held liable for any events beyond our control that will delay the issuance of the applicant’s Passport due to the US Dept of state delay or overnight shipping delay by a third party. Sam’s service fees and the US Passport fees will not be refunded in the event that the issuance of the passport is delayed. Please keep in mind, when dealing with the US passport agency, notification of changes and protocol may change at little or no notice. Please sign here if you have fully read and accepted the terms of the disclaimer and are ready to process your visa application.

Applicant’s Signature _____________________________________

PASSPORT SERVICES

FIRST TIME PASSPORT (ADULTS) $205.00 FIRST TIME PASSPORT (MINORS) $175.00

RENEWAL FOR ADULTS $170.00 RENEWAL FOR MINORS $175.00 SECOND LIMITED PASSPORT $170.00

LOST OR STOLEN (ADULTS) $205.00 LOST OR STOLEN (MINORS) $175.00

PASSPORT CARD – First Time Applicant $125.00 PASSPORT CARD – Minors (under age 16) $110.00

PASSPORT SERVICE TYPE: Please make sure you call us for reservation for same day or 2 working days service

SAME DAY SERIVCE Sam’s Service Fee = $275.00 (Please Call for Reservation) 2 WORKING DAYS SERVICE Sam’s Service Fee = $225.00 (Please Call for Reservation)5 WORKING DAYS SERVICE Sam’s Service Fee = $175.00

10 WORKING DAYS SERVICE Sam’s Service Fee = $125.00 15 WORKING DAYS SERVICE Sam’s Service Fee = $100.00

RETURN POSTAGE – FedEx Overnight

Priority Delivery = $30.00 First Overnight = $75.00 Saturday Fedex = $45.00 International Fedex = $100.00

Total Payment = Passport Fee + Sam’s Service Fee + Return Postage METHOD OF PAYMENT

TYPE OF CARD________CREDIT CARD NUMBER _________________________________________ EXP DATE__________

FULL Billing Address __________________________________________________________________________________

CVV#__________________ (The last three numbers on the back of card for most cards and the four digits on top of American Express Cards)

NAME ON CREDIT CARD____________________________________SIGNATURE______________________ (OF CARD HOLDER)