REPÚBLICA FEDERATIVA DO BRASIL AUTORIZAÇÃO P/ CONCESSÃO DE PASSAPORTE P/ MENOR

MINISTÉRIO DAS RELAÇÕES EXTERIORES COM ANOTACÃO DE AUTORIZACÃO DE VIAGEM

Consulado-Geral do Brasil em Atlanta
3500 Lenox RD NE - Atlanta, GA 30326
Tel: +1 (404)949-2400 - FAX: +1 (404) 949-2402
website http://atlanta.itamaraty.gov.br
e-mail passaporte.atlanta@itamaraty.gov.br
PREENCHER EM LETRA DE FORMA, SEM RASURAS E SEM ABREVIAÇÃO
AUTHORIZATION TO ISSUE BRAZILIAN PASSPORT TO
MINOR WITH TRAVEL AUTHORIZATION
FILL OUT IN ALL CAPITAL LETTERS WITHOUT ERASURES OR ABBREVIATIONS

Pelo presente, autorizo(amos) o Consulado-GeraI do Brasil em Atlanta a emitir documento de viagem para nosso(a) filho(a) menor, identificado(a) a seguir. I (We)
hereby authorize the Consulate General of Brazil in Atlanta to issue a travel document to my (our) child, hereunder identified.
Nome completo do menor / Minor's full name:
Data de Nascim.:
Date of Birthdia / day mês / month ano / year
Sexo/Gender: Masculino Feminino Cidade de Nascimento / UF País de Nascimento
Male Female City of Birth / State Country of Birth

SELECIONE A(S) OPÇÃO(ÕES) ABAIXO DESEJADA(S) / SELECT ONE OR MORE OPTIONS BELOW:
Autorização para CONCESSÃO DE PASSAPORTE PARA MENOR COM ANOTACÃO DE AUTORIZACÃO DE VIAGEM. Na oportunidade, também autorizo(amos), nosso(a) filho(a)
menor, aqui identificado(a), a viajar: / Authorization to ISSUE BRAZILIAN PASSPORT TO MINOR WITH TRAVEL AUTHORIZATION. I (We) also authorize, my (our) minor child, here
identified, to travel:

 desacompanhado; / Unaccompanied ; ou / or
 acompanhado com apenas um dos responsáveis, indistintamente; / Accompanied by either one of the parents; e/ou / and/or
 acompanhado por terceiro / accompanied by a third person,___________________________________________________________________________________________
(nome completo / full name), _______________________________________ (nº Passaporte / # Passport).

SELECIONE A OPÇÃO ABAIXO DESEJADA / SELECT ONE OPTIONS BELOW:

Autorizo(amos) a inclusão de autorização de viagem / I(We) authorize the inclusion of a travel authorization:

 válida pelo prazo do passaporte / valid for the same period of the passport; ou / or
 válida até _____/_____/________ (dia/mês/ano) / valid until _____(day/month/year).
* * * ATENÇÃO: ENVIAR OS DOCUMENTOS ORIGINAIS UTILIZADOS NO PREENCHIMENTO DESTE FORMULÁRIO. (PAIS BRASILEIROS DEVEM ENVIAR DOCUMENTOS BRASILEIROS)
* * * ATTENTION: SEND THE ORIGINAL DOCUMENTS USED IN COMPLETING THIS FORM. (BRAZILIAN PARENTS MUST SEND BRAZILIAN DOCUMENTS)
Nome completo do PAI/Resp. — FATHER's full name: Nome completo da MÃE/Resp. - MOTHER's full name:

Nr. Passaporte/RG - Passport/ID #: Nr. Passaporte/RG - Passport/lD #:

Data de Expedição - Date of Issue: Data de Expedição - Date of Issue:

dia / day mês / month ano / year dia / day mês / month ano / year

Órgão expedidor - Issued by: Órgão expedidor - Issued by:

Assinatura do Pai/Resp - Father's Signature Assinatura da mãe/Resp - Mother's Signature

Notary: Please validate signature bellow, using one stamp per signature.
On ____/____/_____, before me, the undersigned, a notary public for the
State of_____________, County of______________ personally appeared
(full name):___________________________________________________
who proved to me on the basis of satisfactory evidence to be the person whose
name is subscribed to the within instrument and acknowledged to me that he
executed the same in his authorized capacity, and that by his signature on the
instrument the person, or the entity upon behalf of which the person acted, execute
the instrument. I certify, under PENALTY OF PERJURY under the laws of the State of
__________ that the foregoing paragraph is true and correct. Witness my Hand and
Official Seal.
On ____/____/_____, before me, the undersigned, a notary public for the
State of______________, County of______________ personally appeared
(full name):___________________________________________________
who proved to me on the basis of satisfactory evidence to be the person whose name
is subscribed to the within instrument and acknowledged to me that he executed the
same in his authorized capacity, and that by his signature on the instrument the person,
or the entity upon behalf of which the person acted, execute the instrument. I certify,
under PENALTY OF PERJURY under the laws of the State of __________ that the
foregoing paragraph is true and correct. Witness my Hand and Official Seal.

SIGNATURE AND STAMP OF NOTARY PUBLIC SIGNATURE AND STAMP OF NOTARY PUBLIC