2600 South Gessner, Suite 200 Houston, Texas 77063
Specializing in Rush Passports, Visas for all Countries, and Certified Birth Certificates
Phone: (713) 629-8330   Fax: (713) 785-1461
http://www.quickpassport.com email: info@quickpassport.com
NAME CHANGE ORDER FORM
Print this form, fill it out and send it to us with your information

Name(s) in passport/application(s):_____________________    ____________________________

Maiden Name: _____________________________________________________________________

Shipping address and phone number
for Federal Express Delivery:
Address for Saturday Delivery: ( if needed )

__________________________ ______________________________

___________________________ ______________________________
Phone:___________________________________E-Mail _______________________
Have Federal Express deliver without a signature? (circle one)      YES         NO
Phone numbers: Work____________________  Home:_________________ Other:_______________
Date of Birth(s):________________________    _________________________
Date of Departure from the US:_______________
Social Security numbers of applicants (this is required when we have to discuss your application with
the passport agency) SS#____________________________ ________________________________

Payment Information ( please fill in)

PVS Fee*
$109 or **$169 see below

Return Delivery Fee
$30
Total
$____________________
US Goverment Fees (per person)
Circle One
New / Lost Passport
(in sealed envelope)
$170 Adult
$140 Child
Renewal $165
Extra Pages $142
Name Change $60
Passport Card $30
Usbirthcertificate.com/PVS processed my birth certificate (no service fees needed above). If you have our Sales Receipt number
we emailed to you please write it here:_____________________

Credit Card Number:

______________________________
V- Code ( Required)Expires:_____________
Passport And Visa Specialists Fees
Passport Regular Service $109.00
**Passport Next Day Service $169.00 (You must be leaving the country in 3-4 business days for this service). We must receive your package in our office no later than 8:00am. YOU MUST FAX THIS FORM TO OUR OFFICE FOR NEXT DAY SERVICE BEFORE SHIPPING YOUR PACKAGE TO US.
  Passport Card $35
Signature_________________________
Return Delivery Fee:
Federal Express Weekday: $30
Federal Express Saturday $45
*Federal Express First Overnight $70
*Federal Express Same Day Service $250-$400
*Fedex First Overnight and Same day service are not available to all zip codes.
We accept checks, money orders, cashiers checks,Visa, Mastercard and Discover.

*PVS stands for Passport and Visa Specialists' processing fees. Passport and Visa Specialists or any of its agents our not responsible for mistakes or delays from passport offices, consulates, embassies travel agents, overnight courier services, or vital records departments. I understand that the passport office or above agencies can delay or deny passports, visas or birth certificates at their own discretion.