Houston TX 77004 Tel: 713 271 3500 Date : __________________ Applicant's Name : _________________________________ Date of Birth : _____________________________________ Place of Birth : _____________________________________ I authorize the Visa and Passport Courier Representative to submit my passport applications to Houston U.S. Passport Agency and Pick up my passport on my behalf. ___________ I authorize the U.S. Passport Agency to discuss any problems which may arise with my passport application with the courier service. Signature ______________________________ |