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World Service Authority World Office
- 1012 14th Street NW, Suite 205, Washington, DC 20005 USA
- Tel: (202) 638-2662
- Fax: (202) 638-0638
- WSA District Office
- #108 4-5-2 Numabukuro, Nakano-Ku, Tokyo 165, Japan
- Tel: (81)(33) 319-5170
- Fax: (81)(33) 319-5127
THIS APPLICATION FORM IS FREE. Please photocopy if additional forms are required.
INSTRUCTIONS: 1. Print application form. Applications must be
made in writing. 2. Mark which documents and postage you
want (minimum shipping/handling required per applicant). 3. Fill out
personal information in block letters or by typewriter. 4. Sign ATTESTATION OF
UNDERSTANDING AND CERTIFICATION OF INFORMATION. 5. Have your signature
authenticated. 6. Send with 4 photos and bank check in US dollars with US bank name on front of check, international money order in US dollars, international postal money order, Western Union
QuickPay to code city WSA,DC (Western Union only available through the Washington, DC World Office), completed credit card form below (only available through the Washington, DC World Office) or International Response Coupons to : WSA World Office, 1012
14th Street, N.W., Washington, D.C. 20005. Or WSA District Office, #108
4-5-2 Numabukuro, Nakano-Ku, Tokyo 165, Japan. For expedited issuance services, please contact the WSA Washington, DC World Office.
No WSA document will be issued without payment or proof thereof. *Always send proof of payment with application.*
---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 $4 (required minimum) ___ US $7 (with Certified Return Receipt) International Mail: ___ US $8 (required minimum) ___ US $15 (International Registered Mail) (For Office Use Only) WSA#________________ Last Name _____________________________ First Name(s) ___________________________ Street_________________________________ City & Zip 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: ________________________________________ Applicant's Fingerprint: _____________ | | | | | | | | | | | | ------------- This application is free. Please photocopy if additional forms are required. If forms or information in other languages are required, please specify below.Copyright (c) 1995-2004 World Service Authority. All rights reserved.
Send me _______ applications in (Circle only those which apply) English French Spanish German Russian Arabic Japanese. ---------------- 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. Please include a photocopy of the front and back of your credit card. Please note that there are NO REFUNDS or EXCHANGES. Type of Credit Card (Check One): ___Visa ___Mastercard ___Discover ___Diner's Club ___Amex Credit Card Number:_______________________________ Expiration Date (Month/Year): ____________________ Name as it appears on the card: ____________________________ Authorized Signature and Date: _____________________________ Telephone & email of card holder: __________________________ Billing Address including Postal (Zip) Code: _______________________________ ------------------------------------------------------------
Copyright (c) 1995-2004 World Service Authority. All rights
reserved.
If you would like to send mail to World Service Authority,
please use this address:
info@worldservice.org
The World Service Authority, and the human-embracing-the-globe logo are
service marks or registered service marks of the World
Service Authority throughout the world.