Date: _________________

Applicant’s Full Name: _______________________________________________________

Applicant’s Date of Birth: _____________________________________________________

Place of Birth: ______________________________________________________________

 

I authorize Deluxe Passport Express to submit my passport applications to a U.S. Passport Agency and accept delivery of the passport on my behalf.

Under the provision of the Privacy Act of 1974 (Public Law 93-579), no information may be released from U.S. government files without the prior written consent of the individual in question.  Consequently, an employee of the U.S. Passport Agency cannot discuss the details of your passport application with the courier service without your permission.

I authorize the U.S. Passport Agency to discuss any problems, which may arise with my passport application with the courier service identified above.

 

 

Signature __________________________________________

Parents/Guardians signature required for minors under age of 18

 

 

Deluxe Passport Express acts only as an agent and accepts no responsibility for the services of the Passport Agency in connection with the granting of passports, nor for any delays, loss of passports or other materials occasioned by such serviced or by any delivery services such as FedEx, UPS, or the US Postal Service.  Damage compensation is not available.