Dutch Passport Application Page 3
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7This statement is to be dated and authenticated at the Honorary Consul, the Mayor of your City or at a Notary
Public, who will request you to present sufficient evidence of your identity.
DECLARATION OF PARENTAL CONSENT
The undersigned, father and/or mother * of the following minor child(ren)*:
LAST NAME
GIVEN NAME(S)
1___________________________________
_________________________________________
2___________________________________
_________________________________________
3___________________________________
_________________________________________
4___________________________________
_________________________________________
DATE OF BIRTH
PLACE OF BIRTH (CITY)
1___________________________________
_________________________________________
2___________________________________
_________________________________________
3___________________________________
_________________________________________
4___________________________________
_________________________________________
herewith give(s) authorization to the Netherlands Embassy/Netherlands Consulate General:
1. to issue a Netherlands passport in the name of above mentioned child(ren)
or
2. to include the minor(s)* in the Netherlands passport of the father and/or mother* (only possible
when the minor(s) are under the age of 16)
____________________________________
____________________________________
signature father
and/or
signature mother
____________________________________
____________________________________
full name in print
full name in print
-------------------------------------
The above mentioned person(s)* has/have* presented to me sufficient evidence of identity and
has/have* signed this document in my presence.
Signed on: ___________________________________ at _________________________________
__________________________________
Notary / Official’s signature, stamp and title
* = Please cross out what is not applicable
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