To Whom It May Concern:
We, (Parent or Legal Guardian name(s)):
______________________________ & ______________________________
do give our authorization for __________________________ (Traveler's name) as a minor to travel outside the United
States to
________________________________________ (Destination) b
etween the dates of
________________________ & _______________________.
It is my understanding that this information is for consideration by the U.S. Immigration and Naturalization Service in
connection with exit and re-entry into the United States.
Signature(s):
__________________________________ ___________________________________
State of: ________________________
County of: ______________________
Subscribed and sworn to before me this ________day
of __________________ 20_______
______________________
Notary Public in and for the County of _________________ for
the State of _________________________
________________________
My Commission Expires
Notary Seal
KEEP THIS FORM WITH YOU WHEN YOU TRAVEL