PVS International

Please print and complete (include in your package to PVS)

PVS International
1700 N. Moore Street, Suite 310
Arlington, VA 22209
Tel: 703 908 0330
Fax: 703 908 0332

Date Needed back: ______________________________

Company Name (if applicable): ______________________________

Contact Name: _________________________

Address to return Visas/Passports to: ______________________________

.........................................................______________________________
Phone # _____________________

US Departure Date: _____________ ....................Amount Paid: $_____________.

Name(s) on Passport(s): .........................................Passport Number(s):

1. ______________________________.............. ______________________________

2. ______________________________.............. ______________________________

3. ______________________________.............. ______________________________

4. ______________________________.............. ______________________________

5. ______________________________.............. ______________________________

6. ______________________________.............. ______________________________

List countries for Visas: ..............Type of Visa:....... Duration: ...............Type of Entry:

______________________ O Tourist O Business _______ O Single O Double O Multiple

Passport Application:

O New (1st time/or minor)
O Renewal
O Amendment-Pages
O Amendment-Name Change
O Other__________________

For Credit Card Payments:

_ Visa
_ Master Card
_ American Express

Name on Card:

________________________

Card #:

________________________

Card Expiration Date:

________________________

Original Signature of Card Holder:

________________________

Special Instructions/Comments: