AUTORIZAÇÃO PARA CONCESSÃO DE ... .br



CONSULATE GENERAL OF BRAZIL IN BOSTON

Visa Department

175 Purchase Street

Boston, MA, 02110

contato.boston@.br

PARENTAL AUTHORIZATION FOR BRAZILIAN VISA APPLICATION

AUTORIZAÇÃO PARA EMISSÃO DE VISTO PARA MENORES

|1 - MINOR INFORMATION INFORMAÇÃO DO/DA MENOR |

|Full Name Nome e sobrenomes |

|      |

|Place Of Birth (City, State, Country) |Date of Birth Data de Nascimento |

|Lugar de Nascimento (Cidade, Estado, País) | |

| |Day Dia |Month Mês |Year Ano |

|           |      |      |      |

|Passport Information |Issued by (Country and Issuing Office) |Issued on Data de Emissão |

|Number Número |EXPEDIDO POR (País e Autoridade Expedidora) |Day Dia |Month Mês |Year Ano |

|      |      |      |      |      |

|2 –PARENTS/ GUARDIANS INFORMATION INFORMAÇÃO DOS PAIS/RESPONSÁVEIS |

|Guardian 1/Mother’s Full Name (according to minor’s birth certificate) Nome |Guardian 2 / Father’s Full Name (if mentioned on minor’s birth certificate) |

|completo da mãe ou responsável 1 |Nome completo do pai ou responsável 2 (se houver) |

|           |           |

|Passport or ID Passaporte ou documento de identidade |Passport or ID Passaporte ou documento de identidade |

|Number Número |Issued on Data de Emissão |Number Número |Issued on Fecha de Emissão |

| |Day Dia |Month Mês |Year Ano | |Day Dia |Month Mês |Year Ano |

|           |   |   |     |           |   |   |     |

|Issued by (Issuing Office) |Country of Birth |Issued by (Issuing Office) |Country of Birth |

|EXPEDIDO POR (Autoridade Expedidora) |País de Nascimento |EXPEDIDO POR (Autoridade Expedidora) |País de Nascimento |

|           |           |           |           |

|3 – FORMAL STATEMENT DECLARAÇÃO FORMAL |

|I/We authorize the issuance of a Brazilian Visa for the above minor |

|(Autorizamos a emissão de visto para o Brasil para o/a menor acima) |

|Place Local |Date Data |Place Local |Date Data |

| |Day Dia |Month Mês |Year Ano | |Day Dia |Month Mês |Year Ano |

|           |   |   |     |           |   |   |     |

|Guardian 1/ Mother’s Signature Assinatura da mãe ou responsável 1 |Guardian 2 / Father’s Signature Assinatura do pai ou responsável 2 |

|           |           |

|4 – NOTARY’S CERTIFICATION IF PARENT(s) WILL NOT BE PRESENT AT VISA APPLICATION DROP OFF OR APPLICATION WILL BE SUBMITTED BY MAIL: |

|CERTIFICAÇÀO DO NOTÁRIO: caso os pais ou responsáveis legais não estejam presentes na entrevista de solicitação de visto ou enviem o pedido por correio. |

|NOTARY’S CERTIFICATE OF ACKNOWLEDGEMENT FOR FATHER’S SIGNATURE |FOR|NOTARY’S CERTIFICATE OF ACKNOWLEDGEMENT FOR MOTHER’S SIGNATURE |

| |NOT| |

| |ARY| |

| |PUB| |

| |LIC| |

| |USE| |

| |ONL| |

| |Y | |

|State of ___________________ County of _________________________________ | |State of ___________________ County of _________________________________ |

|On_______/________/_________, before me personally appeared | |On_______/________/_________, before me personally appeared |

|____________________________________________________, | |____________________________________________________, |

|□ personally known to me -- OR – | |□ personally known to me -- OR – |

|□ proved to me on the basis of satisfactory evidence to be the person(s) | |□ proved to me on the basis of satisfactory evidence to be the person(s) |

|whose name(s) is/are subscribed to the within instrument and acknowledged to| |whose name(s) is/are subscribed to the within instrument and acknowledged to |

|me that he/she/they executed the same in his/her/their authorized | |me that he/she/they executed the same in his/her/their authorized |

|capacity(ies), and that by his/her/their signature(s) on the instrument the | |capacity(ies), and that by his/her/their signature(s) on the instrument the |

|person(s) or the entity upon behalf of which the person(s) acted, executed | |person(s) or the entity upon behalf of which the person(s) acted, executed |

|the instrument. WITNESS my hand and official seal. | |the instrument. WITNESS my hand and official seal. |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | | |

| | |(Notary’s signature, stamp and commission expiration) |

|(Notary’s signature, stamp and commission expiration) | | |

Note: 1) It is mandatory to add the original birth certificate or its notarized/certified copy on minor’s visa applications.

2) Children of Brazilian nationals must additionally present a declaration of non-citizenship.

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