VISA ORDER FORM
A separate ORDER FORM is required for each traveler

Applicant Information:

Last Name: ____________________________ First Name: __________________________
   
Date of Birth:       /            / US Departure Date:       /            /
   
Day Phone # : __________________________ Home Phone # : _______________________
   
Service Requested: (e.g. Brazil business Visa) : _______________________________________
Ship Passport to:

Name: ________________________________ Phone # : ____________________________
   
Company Name: _________________________________________________________________
   
Company Address: _______________________________________________________________
   
City: ____________________________________ State: __________________ Zip: ________
Payment:

1. If you are paying by check or money order: check or Money Order to Visa Obtainers, Inc. in the amount of: $ ___________

2. If you are paying by credit card: I, herby authorize Visa Obtainers, Inc. to charge all fees associated with this request to the following credit card:

[  ] American Express                 [  ] Master Card                         [  ] Visa

Card Number: ________________________________________________ Exp: _____________

Signature: _____________________________________________________________________
Visa Obtainers, Inc. acts only as an agent on behalf of the applicant and accepts no responsibility for the services of the Passport Agency or Consulate or Embassy regarding the granting of passports or visa or documents legalizations nor for any delay, loss of passport or other materials or documents occasioned by such services or by any delivery services. Damage compensation not available from Visa Obtainers, Inc. please note that visa requirements and fees related to the processing of your visas are subject to change without notice.
FOR OFFICE USE ONLY:

Received on: ______________ Via: __________ Payment Received: ______________________

Returned Shipping On: ______________Via: __________ Airbill: _________________________

Comments: ____________________________________________________________________