World Service Authority, World Office
5 Thomas Circle N.W.,
Washington, D.C. 20005, USA
Tel: (202) 638-2662 Fax: (202) 638-0638
Choose One Passport Cover:___World Passport Cover ___World Government Cover (More Info HERE)
|---World Passport---||___ World Identity Card / US$25|
|___ 10 years / US$100||___ World Birth Card / US$25|
|___ 5 years / US$75||___ World Birth Certificate / US$25|
|___ 3 years / US$55|
|___ 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):(See other shipping options HERE)
Within USA ___ US $5 (required minimum) ___ US $10 (with __Certified Return Receipt or __Priority Mail)
International Mail ___ US $10 (required minimum) ___ US $35 (International Registered Mail)
Choose Format: ___ALL CAPITALS or ___Upper & Lower Case WSA#______________________ (For Office Use Only) Last Name __________________________ First & Middle Names ___________________________ 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) (O) Height____________________ Color of Eyes______________________ Special Marks ________________________ Occupation ___________________________________ (For World Birth Card and Certificate, answer the following:) Father's Name_________________________ Mother's Name_________________________________
Submit 2 photos and print your name on the back of one. Color accepted. Photos should be between 1 and 2 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: By signing below, 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. Fees are non-refundable. The applicant swears that the information on this form is true and correct. Important: Applicants under 18 years of age must have the Attestation of Understanding and Data Consent signed by a parent or guardian.
DATA CONSENT: By signing below, the applicant gives explicit consent (opts in) to provide and share their personal information and data.
Signature and Date
VERIFICATION OF IDENTITY: by 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)or ________ 4-digit CV code (on front of card)
Authorized Signature and Date: _________________________________
Telephone & email of card holder: _______________________________
including Postal (Zip) Code: ____________________________________