US Birth Certificate .Net

3025 Walnut Bend Suite #33 Houston, Texas 77042

Specializing in Rush Passports, Visas for all Countries, and Certified Birth Certificates

Phone: 888-736-2692	Fax: (713) 974-2221
http://www.usbirthcertificate.net	email: info@usbirthcertificate.net

ORDER FORM

Print this form, fill it out and send it to us with your information
DO NOT PUT THIS FORM IN THE GOVERNMENT SEALED ENVELOPE
Once you have all of your information together you need to
Federal Express Priority Overnight it to the following address:

Ship FEDEX ONLY to:
US Birth Certificate. Net
2600 S. Gessner Suite 200
Houston, TX 77063
888-736-2692

Name(s) in passport/application(s):_____________________ ____________________________

******Please write the applicant's full name, date of birth and phone number on the sealed envelope********
Maiden Name : ______________________________________________________________________

Shipping address and phone number for Federal Express:

_________________________________________________

Phone:____________________________________________Email:_____________________________________

Have Federal Express deliver without a signature? (circle one) YES NO

Phone numbers: Work____________________ Home:_________________ Other:_______________

Date of Birth(s):________________________ _________________________

Date of Departure from the US:______________________________

Payment Information -Service Fees( please fill in)

USB Fee*	$99 or **$159 see below
Return Delivery Fee	$25
Total	$___________

US Goverment Fees (per person)
New / Lost Passport (in sealed envelope)	$135 Adult / $120 Child
Renewal	$135.00
Extra Pages	$60.00
Name Change	$60.00

USB processed my birth certificate (no service fees needed above).

Credit Card Number: V-Code(Required)________ ______________________________	US Birth Certificate Fees (USB fee) Passport $99.00 **Passport Next Day Service $159.00 (You must be leaving the country in 3-4 business days for this service)
Expires:_________________________ Signature_________________________	Return Delivery Fee: Federal Express Weekday: $25.00 Federal Express Saturday $40.00 Federal Express First Overnight $65.00 Federal Express Same Day Service $250-$400 *Fedex First Overnight and Same day service are not available to all zip codes

We accept checks, money orders, cashiers checks,Visa, Mastercard, American Express and Discover.

*USB stands for US Birth Certificate. Net processing fees. US Birth Certificate.Net or any of its agents our not responsible for mistakes or delays from passport offices, consulates, embassies travel agents, overnight courier services, or vital records departments. I understand that the passport office or above agencies can delay or deny passports, visas or birth certificates at their own disgression.