AUTORIZAÇÃO PARA EMISSÃO DE PASSAPORTE PARA …

REP?BLICA FEDERATIVA DO BRASIL MINIST?RIO DAS RELA??ES EXTERIORES CONSULADO-GERAL EM CHICAGO

401 North Michigan Avenue, suite 1850, Chicago, IL 60611 Phone: 312-464.0244 / Fax: 312-464.0299 Website: Email: passaporte.chicago@.br

AUTORIZA??O PARA EMISS?O DE PASSAPORTE PARA MENORES AUTHORIZATION FOR PASSPORT ISSUANCE FOR MINORS

Autorizo(amos) a concess?o de passaporte brasileiro ao menor: I (We) authorize the issuance of the Brazilian passport for the following minor: 1- MENOR MINOR

Nome Completo FULL NAME

Preenchimento Obrigat?rio

Natural de (cidade, estado, pa?s) PLACE OF BIRTH (CITY, STATE, COUNTRY)

Data de Nascimento DATE OF BIRTH

Dia DAY

M?s MONTH

Ano YEAR

2 - INFORMA??ES DOS PAIS PARENT'S INFORMATION Nome completo do Pai FATHER'S FULL NAME

Preenchimento Obrigat?rio Nome completo da M?e MOTHER'S FULL NAME

Passaporte n? PASSPORT/ID #

Data de Expedi??o ISSUED ON

Dia DAY

M?s MONTH

Ano YEAR

Passaporte n? PASSPORT/ID #

Data de Expedi??o ISSUED ON

Dia DAY

M?s MONTH

Ano YEAR

?rg?o Expedidor ISSUED BY

?rg?o Expedidor ISSUED BY

SERVI?O OPCIONAL Autoriza??o de Viagem inscrita no passaporte? TRAVEL AUTHORIZATION FOR MINORS INSIDE PASSPORT?

Favor assinalar a op??o desejada: PLEASE CHOOSE ONE OF THE FOLLOWING OPTIONS: O titular est? autorizado pelo(s) genitor(es)/respons?vel legal a viajar:

THE PARENTS/LEGAL GUARDIAN AUTHORIZE THE MINOR TO TRAVEL:

desacompanhado UNACCOMPANIED com um dos pais/respons?vel legal UNDER THE RESPONSIBILITY OF ONE OF THE PARENTS/LEGAL GUARDIAN acompanhado por terceiro UNDER THE RESPONSIBILITY OF

Validade da autoriza??o: AUTHORIZATION VALIDITY.

pelo prazo do passaporte WITHIN THE VALIDITY OF THIS DOCUMENT

at? a data de UNTIL THE DATE

/

/

Nome NAME

Preenchimento Opcional

Autorizado

AUTHORIZED

Sim YES

N?o NO

Passaporte n? : PASSPORT #

3 - TERMO DE RESPONSABILIDADE FORMAL STATEMENT

Preenchimento Obrigat?rio

Declaro(amos) serem verdadeiras e completas as informa??es contidas no presente documento.

I (We) declare that the above information is true and accurate.

Local PLACE

Data DATE

Local PLACE

Data DATE

Dia DAY

M?s MONTH

Ano YEAR

Dia DAY

M?s MONTH

Ano YEAR

Assinatura do Pai FATHER'S SIGNATURE

Assinatura da M?e MOTHER'S SIGNATURE

4 - RECONHECIMENTO NOTARIAL * NOTARY'S CERTIFICATION*

NOTARY'S CERTIFICATION FOR FATHER'S SIGNATURE Notary:Please validate signees using ONE STAMP PER SIGNATURE.

Please also indicate your State, Country and Comm. Expiration.

NOTARY'S CERTIFICATION FOR MOTHER'S SIGNATURE Notary:Please validate signees using ONE STAMP PER SIGNATURE.

Please also indicate your State, Country and Comm. Expiration.

FOR NOTARY PUBLIC USE ONLY

RECONHECIMENTO NOTARIAL NOTARY'S CERTIFICATION IMPORTANTE: Cidad?os de outras nacionalidades devem ter suas assinaturas reconhecidas por Not?rio P?blico da jurisdi??o consular antes de apresentar ou enviar sua solicita??o ao Consulado. A assinatura do Not?rio dever? ser certificada pelo Secretary of State ou County Clerk. Cidad?os brasileiros que n?o puderem comparecer pessoalmente ao Consulado devem ter suas assinaturas reconhecidas por Not?rio P?blico da jurisdi??o consular antes de enviar sua solicita??o ao Consulado. A assinatura do Not?rio dever? ser certificada pelo Secretary of State ou County Clerk.

IMPORTANT: Citizens of other countries must sign this form in front of a Notary Public within the consular jurisdiction, before presenting or sending it to the Consulate. The Notary's signature must be certified by the Secretary of State or county Clerk. Brazilians citizens who cannot come to the Consulate must sign this form in front of a Notary Public within the consular jurisdiction, before sending it to the Consulate. The Notary's signature must be certified by the Secretary of State or county Clerk.

Revisado em 26/11/2014

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