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