I (we) authorize the minor child
_________________________________________________________
with passport or drivers license number ________________________ issued by
________________
on ____ / ____ / ____ and being born in ______________________________ on ____ /
____ / ____
to travel on any occasion to and within the territory of
_____________________________________
as well as to return to the country of residence, unaccompanied or under the
responsibility of
____________________________________________________ of ______________________
nationality
and residing at
________________________________________________________________________
with passport or drivers license number _____________________ issued by
__________________
on ____ / ____ / ____ and being born in _____________________________ on ____ /
____ / ____
and being the legal or birth ___________________________________________ of the
minor child.
Signed ___________________________ on ____ / ____ / ____
Notary Public signature and seal below