Form DS-5538 Courier Company Registration Form

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OMB CONTROL NO. 1405-XXXX
OMB EXPIRATION DATE: XX-XX-XXXX
ESTIMATED BURDEN: 20 MINUTES

U.S. Department of State

Courier Company Registration Form

You must fill out the form in its entirety. If you have any questions, please contact the National Courier Liaison at NationalCourierLiaison@state.gov.

Part 1: To Be Filled Out By Courier Company Owners
NOTE: The company owner(s) must submit the following with this form:
1. A clear photocopy of a valid business license that shows the business license number, issuing state, and date of issuance.
2. A clear photocopy of each owner's government-issued photo identification, such as a driver's license, U.S. passport, or military identification.
Company Name

Doing Business As ("DBA") Name (if applicable)

Full Name of Company Owner #1 (Last, First, Middle)

Full Name of Company Owner #2 (Last, First, Middle)
Company Address (Include Number, Street,City, State and Zip Code)

Point of Contact ("POC") for the Passport Agency to contact with questions

POC Job Title

Company Website

POC Phone Number

POC Email

Mailing Address (if different from Company Address above)

Please list the U.S. Passport Agency at which you wish to register.

Has the company owner(s) previously owned and/or currently own a different registered courier company? If so, list the name of each courier
company and the U.S. passport agencies where they were registered. (Attach a separate sheet, if needed.)

Part 2: To Be Filled Out By Courier Company Owner #1
Full Name of Company Owner (Last, First, Middle)

Owner's Phone Number

Owner's Email

By selecting the following boxes and signing below, you certify that all the following are true.
You are at least 18 years old.
You are a U.S. citizen or national, lawful permanent resident, or legally authorized to work in the United States.
You have never been convicted of a felony.
You have never been convicted of a federal, state, or local misdemeanor related to the mismanaging of funds, identity theft, document fraud, or a
drug offense.
You are not currently under indictment or investigation for a felony or for any crime related to mismanaging funds, identity theft, document fraud, or
a drug offense.
NOTE: You must include a photocopy of the front and back of your government-issued photo identification.
I declare under penalty of perjury all of the following: 1) The statements in Sections 1 and 2 are true and correct, 2) I have not knowingly and
willfully made any false statements or provided false documents in support of this registration, and 3) I have read and understood the
warning on this form.

Signature of Courier Company Owner #1
DS-5538 XX-XXXX

Date
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Part 3: To Be Filled Out By Courier Company Owner #2 (if more than one)
Owner's Phone Number

Full Name of Company Owner (Last, First, Middle)

Owner's Email

By selecting the following boxes and signing below, you certify that all the following are true.
You are at least 18 years old.
You are a U.S. citizen or national, lawful permanent resident, or legally authorized to work in the United States.
You have never been convicted of a felony.
You have never been convicted of a federal, state, or local misdemeanor related to the mismanaging of funds, identity theft, document fraud, or a
drug offense.
You are not currently under indictment or investigation for a felony or for any crime related to mismanaging funds, identity theft, document fraud, or
a drug offense.
NOTE: You must include a photocopy of the front and back of your government-issued photo identification.
I declare under penalty of perjury all of the following: 1) The statements in Sections 1 and 3 are true and correct, 2) I have not knowingly and
willfully made any false statements or provided false documents in support of this registration, and 3) I have read and understood the
warning on this form.

Signature of Courier Company Owner #2
(if more than one)

Date

WARNING
Knowingly and willfully providing false statements or documents in connection with this form is punishable by fine and/or imprisonment under U.S. law,
including 18 U.S.C. 1001. In addition, providing false information on this form or otherwise failing to abide by the requirements of the procedures for
passport couriers outlined in 22 C.F.R. Part 54 may result in the suspension, cancellation, or ban of employee and/or courier company's registration to
hand carry passport applications.

PRIVACY ACT STATEMENT
AUTHORITIES: Collection of the information on this form is authorized by Titles 8 and 22 of the United States Code, and other applicable laws and
regulations, including 22 U.S.C. 2651a et. seq.; 8 U.S.C. 1104; Executive Order 11295 (August 5, 1966); and C.F.R. Parts 50, 51, and 54.
PURPOSE: The primary purpose for soliciting this information is to determine the company's eligibility to register to perform hand carry services at
participating U.S. passport agencies pursuant to 22 C.F.R. Part 54.
ROUTINE USES: This information solicited on this form may be made available as a routine use to other government agencies for fraud prevention,
law enforcement, and administrative purposes. For a detailed listing of the routine uses for which this information may be disclosed, see the
Department of State's Prefatory Statement of Routine Uses relative to the Privacy Act (Public Notice 6290 of July 15, 2008) and the listing of routine
users set forth in the System of Records Notices and Passport Records (State-26) published in the Federal Registrar.
CONSEQUENCE OF FAILURE TO PROVIDE INFORMATION: Failure to provide the information requested on this form may, may result in Passport
Services' refusal to accept this company's registration to provide hand carry services.

PAPERWORK REDUCTION ACT
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time required for searching
existing data sources, gathering the necessary data, providing the information and/or documentation required, and reviewing the final collection. You
do not have to supply this information unless this collection displays a currently valid OMB control number. If you have comments on the accuracy of
this burden estimate and/or recommendations for reducing it, please send them to: U.S. Department of State, Bureau of Consular Affairs, Passport
Services, Office of Program Management and Operational Support, Attn: Passport Forms Officer, 44132 Mercure Cir., P.O. Box 1199, Sterling, Virginia
20166-1199.

DS-5538 XX-XXXX

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