Approved - ND003
Expires - 31/12/2005
Est. burden 1/2H
 
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PLEASE WRITE VERY CLEARLY USING ONLY CAPITAL (BIG) LETTERS

Due to the nature of mail payments USAFIS Organization cannot guarantee or ensure arrival of offline payments. We strongly suggest using our secured and encrypted website for making online credit card payments. Any other payment method is at your own discretion and risk.

Applicant Details
First Name: MASOUD Last Name: KHANMOHAMMADI
Date Of Birth: 8-9-1979 Country of Birth: IRAN
User Number (*Optional only if was provided):
 
Mailing Address
Street and number: #438 SEYMOUR ST. City/Town: VANCOUVER , BC
District/County/Province: CANADA/BC Zip code: V6B 6HA
Country: CANADA Phone: 1-604-6965557
Email: masoudla@yahoo.com
Confirm Email (Write email address again): masoudla@yahoo.com
IMPORTANT:  I have entered my personal information (name, address, date of birth...) in the online system
 
Select Option Mark your choice with a x
US dollars
Euro (same amount as in US$)
 
Instructions Read Carefully and follow the instructions.
  • Send cash as registered or insured mail.

  • Wrap cash with additional envelope or paper to prevent see-through mail envelope.
 
Service and Fee
Mark with x Select your Service Price
Your application for 1 year 49$
Your application for 2 years
50% discount on 2nd year!		 69$
You & Your Husband/Wife applications for 1 year
Double Your Chances!		 79$
You & Your Husband/Wife applications for 2 years
Best value: 70% discount on 2nd year		 99$
Your application for 4 years
Free Year! 		119$
You & Your Husband/Wife applications for 4 years
Free Year + Double Your Chances		 199$
 
TERMS AND CONDITIONS, Alternate Payment Addendum
By signing below you accept and agree to USAFIS Organization's "Terms and Conditions" as published on www.usafis.org website and to the following "Alternate Payment Addendum":
  1. You accept and agree that the payment method selected and executed herein is at your own discretion and risk. You accept and agree that USAFIS Organization is not responsible for loss of payment sent in by mail.
  2. You accept and agree that your payment is non-refundable whether you decide to continue with the process or not. Under no circumstances a refund (pay back) will be provided and the sole purpose of this payment is for rendering USAFIS Organization services as selected in this form.
  3. USAFIS will provide the service 14 days after receiving payment.
I READ, ACCEPT AND AGREE:
________________ ________________
SIGNATURE DATE
 
After completing all details and enclosing payment, mail this form to:

PROCESS DEPARTMENT, USAFIS ORGANIZATION
2565 BROADWAY # 520, NEW YORK NY 10025, USA

PLEASE NOTE:
  • Cash payments are generally a safe method for most countries, provided the cash is well concealed in an envelope.
  • Make sure cash payment sent by mail is authorized in your countries.
  • USAFIS will provide the service 14 days after receiving payment. A message will be sent to your email address with login information.

Use this label to mail your payment (cut and paste on envelope):



PROCESS DEPARTMENT
USAFIS ORGANIZATION
2565 BROADWAY # 520
NEW YORK NY 10025
U.S.A.

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