Services Order
Form
WHAT TO INCLUDE:
1. Documents
2. This order form
3. Payment (check or money order payable to US Authentication Services, PayPal, or cc information on this form)
4. Prepaid return label or payment for label
ADDRESS: 7015 Old Keene Mill Road, Suite 203, Springfield VA 22150 EMAIL: info@usauthentication.com
Contact Information:
First Name: Last Name: __________________________________________________
Address: _________________________________________________________________ Suite/Apt#: __________________________
City: State: Zip Code: Country: _____________________________
Email address: ________________________________________________________
Phone number: __________________________
Document Information: (Please list only the specific documents to be Apostilled/Authenticated)
1. _________________________________________________________________________________________________________
2. _________________________________________________________________________________________________________
3. _________________________________________________________________________________________________________
4. _________________________________________________________________________________________________________
Total # of documents: _____________ Country documents will be used in: ________________________ Subtotal: $______________
Return Mailing Information:
Name: ____________________________________________________________
Company: _________________________________________________________
Address: __________________________________________________________
City: ______________________________________________________________
Postal code: __________ State: _______ Country: _________________________
Contact Phone number: ______________________________________________
(check one box)
Prepaid return label provided
FedEx Domestic 2 Day mailing: $ 35.00
o Signature Required (Y/N) __________
FedEx International mailing $__________
(see page 2 for rates)
Grand Total: $___________
Payment Information (check one box)
Method of payment: Check Money order Credit Card PayPal # ________________________________
Credit Card information (if applicable):
Card Number: ______________________________________________Exp. Month/Year: _____________ Security Code: __________
Full Name as appears on Card: ______________________________________________________ Billing Zip Code: _____________
By signing below I authorize US Authentication Services to charge my credit card US$ for all the services rendered,
in addition to a 4% credit card convenience fee.
Cardholder Signature (required if paying by credit card):
I authorize US Authentication Services to obtain Apostille or Document Authentications on my behalf. I agree to indemnify and to hold US
Authentication Services, its employees, agents and affiliates harmless from all liability and expenses, including reasonable attorney’s fees that
maybe incurred as a result of my instructions. I understand that US Authentication Services cannot, and does not, make any guarantees or
warrantees regarding my request to Apostille or certify my document(s) and also cannot guarantee any shipping and delivery times.
Signature (to process order)
: Date:
©US Authentication
Services
7015 Old Keene Mill Road Suite 203| Springfield, VA 22150
(703) 971 7226
info@usauthentication.com | www.usauthentication.com
