Thursday, August 10, 2006 Thank you for contacting CIBT, your ...
Thursday, August 10, 2006 Thank you for contacting CIBT, your ...
Thursday, August 10, 2006 Thank you for contacting CIBT, your ...
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VISA & PASSPORT SUBMISSION SHEETCall us <strong>for</strong> assistance -TRAVELER INFORMATION:My company's <strong>CIBT</strong> account number is:Date passport must be back in <strong>you</strong>r possession: / /mm dd yyyyDate of next international trip: / /mm dd yyyyGreen Card Holder: Yes: No:Name:LastFirstE-Mail:Contact Name:RETURN DOCUMENTS TO THIS ADDRESS:Phone:Fax:Name:Company:Street: City: State: Zip:NO PO BOXESTelephone Number:I Authorize Delivery w/o Signature: Name (print)The address listed above is: Residential: Business:Signature:SERVICES REQUESTED:Select the type of service <strong>you</strong> request by placing a check mark in the appropriate box <strong>for</strong> each service <strong>you</strong> are ordering.Passport: First time: Renew: Pages:2nd Passport:If within 12months ofdate of issueExtend Validity:In<strong>for</strong>mation Change:Visas:Tourist:Business:Transit:Number of Entries:Country #1:Country #2:Country #3:I understand that any visa request that is needed in seven business days or less OR any passport request that is needed in tenbusiness days or less will be assessed a rush or emergency surchargePAYMENT METHOD FOR APPLICABLE FEES:American Express: Diners Club: MasterCard: Visa: Discover: Money Order: Check: #I hereby authorize <strong>CIBT</strong> to charge the cost of its professional visa and passport services to the following credit card. I agree to pay this amount to my credit cardcompany.Name on Card:Card Number:<strong>CIBT</strong> CHICAGO180 North Stetson Ave, Suite 3170,Chicago, IL 60601<strong>CIBT</strong> HOUSTONTwo Greenway Plaza, Suite 275,Houston, TX 77046Expiration Date:mm/yy<strong>CIBT</strong> LOS ANGELES6300 Wilshire Bvd, Suite 1520,Los Angeles, CA 90048Signature:<strong>CIBT</strong> MIAMI169 East Flagler St., Suite 1438,Miami, FL 33131<strong>CIBT</strong> NEW YORK60 East 42nd Street, Suite 1250,New York, NY <strong>10</strong>165<strong>CIBT</strong> SAN FRANCISCO625 Market Street, Suite <strong>10</strong><strong>10</strong>,San Francisco, CA 94<strong>10</strong>5<strong>CIBT</strong> WASHINGTON, DC2233 Wisconsin Ave, Suite 215,Washington, DC 20007FOR <strong>CIBT</strong> ONLY:Itinerary #:Date Received:Via:Missing/Inadequate Docs: PPT / APP / PHO / BCL / Other:Agent:Original Documents Included:PPT Cover / GC / I-94 / Nat Cert / INS Docs / TIX / BC / MC / DC / VACC CertDate Returned:Via:FDX / UPS / DHLAccount #: Invoiced by: Waived Signature Release: Yes / NoPayment Received: Credit Card Check/Money Order #: Amount:Code:Page 7 of 7