Sistemas.mre.gov.br
14204075181603150 SW 38th Avenue Suite 100 Miami, FL 33146 / Visa SectionWebsite: miami..br E-mail: visa.miami@.br(The Visa Department does not provide assistance by phone)003150 SW 38th Avenue Suite 100 Miami, FL 33146 / Visa SectionWebsite: miami..br E-mail: visa.miami@.br(The Visa Department does not provide assistance by phone)We, the parents/guardians hereby identified, authorize the Consulate General of Brazil in Miami to issue a visa on our child's passport. Our child is also authorized to travel to Brazil and within the Brazilian territory for the duration of his/her visa, as follows:Unaccompanied □ Under the responsibility of______________________________________________Father's □ Guardian's information:1. Full name:_________________________________________________________________________2. Country of birth:_________________________________3. Is a Brazilian citizen? □ YES □ NOMother's □ Guardian's information:1. Full name:_________________________________________________________________________2. Country of birth:_________________________________ 3. Is a Brazilian citizen? □ YES □ NOChild's information:1. Full name:_________________________________________________________________________2. City/State/Country of birth: _____________________/___________________/__________________3. Date of birth: (DAY/MONTH/YEAR) _________/_________/____________4. Has he/she ever been issued a Brazilian Birth Certificate with a Brazilian Consulate / Embassy or Civil Registrar in Brazil? □ YES □ NO5. Has he/she ever been issued a Brazilian Passport? □ YES □ NOAs a guardian, I declare under penalty of perjury according to any applicable Law that I have sole custody, legal guardianship, of the child identified above.I/we understand that any knowingly and willfully false of misleading statement of willful concealment of a material fact made by me/us herein may subject me/us to criminal prosecution under Brazilian Penal Code:"Article 299: Concealing in public or private document, a declaration which it should contain, or inserting or making false statement or insert any information other than that which should be written with the purpose of disrupting law, create an obligation or alter the truth of fact legally relevant."__________________________ __________________________ Father's/Guardian's signature Mother's/Guardian's signature ................
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