Passport Privacy Release Form

"*" indicates required fields

Contact Information

Prefix*

First Name*

Last Name*

Address*

Street Address Address Line 2 City State ZIP Code

Email*

Enter Email Confirm Email

Date of Birth*

Phone*

Social Security Number*

Passport Information

Date of Travel*

Have you already applied for your passport?*

Location Number*

If so, when did you apply?*

Did you pay for expedite?*

Did you pay for overnight shipping?*

If no, are you interested in paying for these services?*

Check either option

Expedite $60

Overnight shipping $19.53

Brief description of the issue*

Please print document and add your signature. You are welcomed to mail the document to the closest office, by email at Casework@cortezmasto.senate.gov, or by fax at 702-388-5030.

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