Date : __________________

Applicant's Name : _________________________________

Date of Birth : _____________________________________

Place of Birth : _____________________________________

I authorize an agent of your agency 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 release 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 ______________________________