WRITTEN CONSENT FOR CHILD UNDER 18 YEARS
TRAVELING WITH ONLY ONE PARENT OR WITHOUT EITHER PARENT
TO WHOM IT MAY CONCERN:
I(WE) AUTHORIZE THE MINOR
NAME PASSPORT NO.
DATE OF BIRTH / /
TRAVEL TO FROM / / TO / /
Purpose of His / Her Trip is
□ ACCOMPANIED BY THE FOLLOWING PERSON(S);
Name （ Relation )
Address
DATE OF BIRTH / / TEL
PASSPORT NO.
□ UNDER THE RESPONSIBILITY OF
ACCOMPANIED PARENT’S DATE OF BIRTH
PASSPORT NO.
□ REFERENCE(ex : HOTEL)
Name ( Relation HOTEL / OTHERS )
Address
TEL
FATHER(PRINT NAME) MOTHER(PRINT NAME)
CONTACT INFORMATION(PHONE NUMBER,etc.) CONTACT INFORMATION (PHONE NUMBER,etc.)
SIGNATURE SIGNATURE
/ / / /
DATE DATE
WE SOLEMNLY SWEAR THAT HE / SHE SHALL COMPLY WITH THE LAWS AND REGULATIONS OF YOUR
COUNTRY,FEDERAL AND LOCAL,NEVER BE A BURDEN,ECONOMIC OR OTHERWISE,TO YOUR COUNTRY AND
DEPART COUNTRY WITHIN THE REASONABLE TIME NEEDED FOR TRANSFERS TO AND FROM JAPAN.
WE WOULD APPRECIATE IT VERY MUCH IF YOU WOULD TAKE THE NECESSARY ACTION TO GRANT HIS
/ HER THE ENTRY PERMIT TO YOUR COUNTRY AT YOUR EARLIEST POSSIBLE CONVENIENCE.
THANK YOU FOR YOUR COOPERATION.
