ASSENSO DELL’ALTRO GENITORE DEI FIGLI MINORENNI
CONSENT FORM TO BE COMPLETED BY THE OTHER PARENT OF CHILDREN UNDER 18
Dichiarazione sostitutiva di certificazioni (Art.46 D.P.R. 445 del 28/12/2000)
Il/La sottoscritto/a consapevole delle sanzioni penali, nel caso di dichiarazioni non veritiere e falsità negli
atti, richiamate dall’art.76 D.P.R.445 del 28/12/2000
I the undersigned, being fully aware of the criminal penalties imposed for making false declarations,
as per art. 76 of Presidential Decree no. 445 of 28/12/2000,
DICHIARA / HEREBY DECLARE THE FOLLOWING:
Il/La Sottoscritto/a ______________________________________________________________________________
The Undersigned COGNOME - DA NUBILE PER LE SIGNORE - (Surname - Maiden name for ladies -) NOME (First name/s)
nato/a a____________________________________________________ il_________________________________
place of birth CITTA’ E PROVINCIA (Town and County) date of birth day-month-year
Indirizzo di residenza___________________________________________________________________________
Address VIA E NUMERO CIVICO (Street and house/flat number)
____________________________________________________________________________________________________________________________________________________________
CITTA’ E PROVINCIA (Town and County) CODICE POSTALE (Post Code)
genitore dei seguenti figli minorenni/parent of the following children under the age of 18:
COGNOME (Surname) NOME (First name) NATO/A A (place of birth) IL (date of birth) Sesso(Sex)
acconsente che sia rilasciato il passaporto/carta d’identità/E.T.D (emergency travel document)
hereby give my consent for the issue of a passport/ID Card/ E.T.D (emergency travel document)
al/alla:
to:
Sig/[Link] ____________________________________________________________________________________
Mr/Miss/Mrs COGNOME - DA NUBILE PER LE SIGNORE- (Surname - Maiden name for ladies -) NOME (First name/s)
nato/a a____________________________________________________ il_________________________________
place of birth CITTA’ E PROVINCIA (Town and County) date of birth day-month-year
Indirizzo di residenza___________________________________________________________________________
Address VIA E NUMERO CIVICO (Street and house/flat number)
____________________________________________________________________________________________________________________________________________________________
CITTA’ E PROVINCIA (Town and County) CODICE POSTALE (Post Code)
Data__________ Firma del genitore che rilascia l’assenso
Date
Signature of the other parent giving consent
Si allega documento di identita’, in originale o fotocopia, con foto e firma.
I enclose my photographic identification document (original or photocopy) including my signature.