Peninsula Visa and Passport Service

Tel: 800-665-VISA
408-727-7514
Fax: 408-727-7516

To: U.S. Department of State
      Passport Agency

I,________________________________________________________________ authorize
            (full name and birth date)
Peninsula Visa and Passport Service to pick up my passport and to discuss the status of my application with the Passport Services Staff.

My departure date from the United States is ______________________.

________________________________________
Signature of Applicant

(  )  Please do not fold Birth Certificate  or Citizenship / Naturalization Certificate
      (Peninsula Visa cannot be held responsible for the folding of these documents.)

________________________________________
Signature of parent if applicant is under age 18

Complete if Applicable:
I am requesting that my application for passport be expedited, as I will also be required to apply for visas for the following country/ies:_____________________________________________.
A copy of my itinerary or air tickets are enclosed as confirmation.

THIS LETTER IS NOT ACCEPTED ON THERMAL FAX PAPER.