Ambassador Passport and Visa Services, Inc.
2811 Wilshire Blvd., Suite 720, Santa Monica, CA 90403 Tel: (310) 828-7878 Fax: (310) 828-7474 AmbassadorPassportandVisa.com Email: firstname.lastname@example.org
This form is to advise Ambassador Passport a nd Visa Services of the type of service you are requesting, the departure date of your trip, and the return address for the completed documents to be mailed to. In order to properly process your requested service, please include this form with your Passport / Visa application
From: Full Name of Applicant: Company Name: Address: Telephone:
Passport Services Requested:
Additional Passport Pages
__Passport Amendment __Other
First Time Passport
Processing Time: __Regular (12 working days) __
Express (6 working days) __
Rush (48 hrs) __Ultra Rush (24 hours)
Visa Processing Requested: (Please list the countries you require Visas expedited for, processing time , and check number of entries)
1 - Name of Country: 2 - Name of Country: 3 - Name of Country:
__Single Entry __ __Single Entry __ __Single Entry __
Double Entry __ Double Entry __ Double Entry __
Multiple Entry __ Multiple Entry __ Multiple Entry __
Other Other Other
Rush __Ultra Rush
Date documents are needed:
I understand that any request that is needed in less than five business days will be assessed a
rushed processing surcharge.
Payment method: __American Express Cardholder’s Name: Card Number:
I______________________ hereby authorize Ambassador Passport and Visa Services to charge the cost of services rendered to the above credit card.
Day Air) __
FEDEX (Saturday Delivery) __Will Call
Name: Company Name: Address: City, State, and Zip:
Statement of Non-Liability: Ambassador Passport and Visa Services, Inc. is not responsible for mistakes, delays, or decisions by the U.S. Government, passport offices, consulates, embassies, travel agents, courier services, foreign governments, various records departments, as well as uncontrollable events such as forcemajeurs and acts of God. I understand that the passport office or visa office or any of the above agencies can delay or deny passports, visas or birth certificates. Ambassador Passport and Visa Services, Inc. will not be held liable for any financial loss occurred by delay in the process. Regardless of the result, Ambassador Passport and Visa Services can collect its fees, once the service has been conducted. By submitting this application, you agree to these terms.