World Service Authority, World Office |
5 Thomas Circle N.W.,
Washington, D.C. 20005, USA
Tel: (202) 638-2662
Fax: (202) 638-0638
|---World Passport---||___ World Identity Card / US$20|
|___ 8 years / US$100||___ World Birth Card / US$20|
|___ 5 years / US$75||___ World Birth Certificate / US$20|
|___ 3 years / US$45|
|___ World Donor Passport (15 years)|
(The World Donor Passport is issued for a donation of at least US$400 to the World Refugee Fund, which enables the WSA to issue free WSA documents to needy refugees and stateless persons. The World Donor Passport is similar to a regular WSA World Passport except that it has a special, gold-embossed cover and is valid for a 15-year period.)
Required US and international shipping and handling fees (per applicant):
Within USA ___ US $5 (required minimum) ___ US $10 (with Certified Return Receipt)
International Mail ___ US $10 (required minimum) ___ US $25 (International Registered Mail)
(For Office Use Only) WSA#______________________ Last Name __________________________ First Name(s) ___________________________ Street______________________________ City & Postal Code ______________________ State Province______________________ Country _________________________________ Telephone___________________________ Fax _____________________________________ Email and Personal Internet Web Site _________________________________________ Place of Birth________________________________________________________________ Date of Birth DAY:___________ MONTH:_________________________ YEAR:___________ Gender (M) (F) Height___________________ Color of Eyes____________________ Special Marks ______________________ Occupation ______________________________ (For World Birth Card and Certificate, answer the following:) Father's Name_____________________ Mother's Name______________________________
Submit 4 photos and print your name on the back of each one. Color accepted. Photos should be between 1 and 1 3/4 inches. Photos are for file, replacement if necessary, and ID card, in addition to passport.
Address to which documents should be sent:
ATTESTATION OF UNDERSTANDING AND CERTIFICATION OF INFORMATION: The applicant understands that the World Service Authority accepts no responsibility for the position of any government as regards the acceptance of the WSA passport and/or its other identification documents. The applicant is solely responsible for the use of the passport and accompanying documents, which are the bearer's property. The applicant swears that the information on this form is true and correct. Important: Applicants under 16 years of age must have the Attestation of Understanding signed by a parent or guardian.
Signature and Date
CERTIFICATION OF SIGNATURE, OR PHOTOCOPY OF IDENTITY PAPERS, OR PRINT OF RIGHT INDEX FINGER
On this ______ day of ______________, 20____, before me came_________________________________________, known to me and known by me to be the person who executed the foregoing application, and he/she thereupon duly acknowledged to me that he/she executed the same.
Certifying Official Signature and Seal:
_____________________ | | | | | | | | | | | | | | ---------------------
If you require forms or information in other languages, please specify below.
|Send me _____
CREDIT CARD PAYMENT FORM
You may make donations and pay service fees by credit card. Please complete the form below and return it to the WSA with the completed application form above. You must include a photocopy of the front side and back side of your credit card. Please note that there are NO REFUNDS or EXCHANGES.
Type of Credit Card (Check One):
Credit Card Number:________________________________ Expiration Date (Month/Year): _________
Name as it appears on the card: ________________________________ 3-digit CV code: ________(on back side of card)
Authorized Signature and Date: _________________________________
Telephone & email of card holder: _______________________________
including Postal (Zip) Code: ____________________________________