Parental Consent Form
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1Regionale Service Organisatie
Noord Amerika en Caraibisch Gebied
To be completed by:
- the non-applying parent (guardian) when (s)he will not be present in person at the time of application; OR
- parent (guardian) who does not hold the Dutch nationality
Item 3b is ONLY required when you are not appearing in person AND cannot submit you original ID to the applying parent
PARENTAL CONSENT FORM
The parental consent form cannot be more than 3 months old
1a. MINOR'S NAME
Last:
First:
Middle:
1b. MINOR'S DATE OF BIRTH
1c. YOUR RELATIONSHIP TO MINOR
2a. MINOR'S NAME
Last:
First:
Middle:
2b. MINOR'S DATE OF BIRTH
2c. YOUR RELATIONSHIP TO MINOR
3a. STATEMENT OF CONSENT
I, ___________________________________________________ give my consent to the issuance of a
(print your full name)
Dutch passport to my minor child/children named on this application.
_____________________________________________
_________________________
Signature of parent/guardian
date
Make sure your signature matches the one in the ID you are presenting
3b. STATEMENT OF CONSENT NOTARIZATION
Only needed when you are not appearing in person and the applying parent is not bringing your original ID.
Name of Notary: ___________________________
Print Name
NOTARY
Location:
__________________________
SEAL
City, State
Commission Expires ________________ __
Date (mm/dd/yyyy)
Signature of Notary _________________________
Date of notarization: __________________
Date (mm/dd/yyyy)
Identification Presented by Non-Applying Parent / Guardian:
passport
Driver's license
ID number:
Expiration date:
__________________________
__________________________
Notarized copy of the ID needs to accompany the consent statement
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