Express Travel Services, Inc
www.MyVisaPassport.com
1-866-376-1125
Passport and Visa Request Form
TRAVELER INFORMATION     Green Card
Date Passport must be back mm dd yy   H1B 
L1   
Date of Departure (International) mm dd yy Time US Citizen
Other
Name
Last First Middle
Phone  Email   Fax 
Residential address/Billing address
Name
Street  City State  Zip
No PO Box
Telephone   (W)   (M)
   SERVICE REQUESTED
   Passport: First Time  Renewal Additional Pages Lost Passport   Other 
   Visas:   Tourist Business Entries
   Destination 1 Single/Multiple
   Destination 2 Single/Multiple
   Destination 3 Single/Multiple
Mode of Payment
Card Type Visa Master Personal Check  Company Check   AMEX Pay Online Cash
Express Travel Services acts only as an agent on behalf of the applicant and accepts no responsibility for the services ofthe Passport Agency or any Consulate or Embassy regarding the granting of passports or visas, nor for any delays, lossof passports or other materials or documents occasioned by such services or by any delivery services. Damage orCompensation is not available from Express Travel Services.
I hereby agree to pay for services rendered :- Signature
Express Travel Sevices, 5755 Oberlin Drive, Suite 301, San Diego, CA 92121, Tel 1-866-376-1125
Email :- info@etsonweb.com    www.MyVisaPassport.com