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Passport Credit Card Authorization Form

 American Citizen Services Unit, Embassy of the United States of America,
 Buenos Aires, Argentina

I,_____________________________________________________,
    (Name as it appears on credit card)

authorize the Embassy of the United States of America at Buenos Aires,

Argentina, to charge 75 US dollars for passport services from my

_________________________________________international credit card,
(Visa/Mastercard/American Express/Discover)

#________________________________________,
   (card number)

expiring _________/_________.
      (Month)       (Year)

_________________________________  
(Signature of cardholder)

____________________________________________________________
(Address of cardholder)

__________________
(Telephone of cardholder)

PASSPORT APPLICANT’S NAME:

……………………………………………………………………………….