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REP BLICA FEDERATIVA DO BRASIL MINIST RIO DAS RELA ES EXTERIORES CONSULADO-GERAL EM MIAMI FORMUL RIO PARA CARTEIRA DE MATRICULA CONSULAR - CMC 80 SW 8ST 26Tth floor Miami FL 33131-3004 USA Phone 305-2856200 / Fax 312-285-6240 Website www. brazilmiami. org Email registros brazilmiami. org 1 - DADOS PESSOAIS Nome Completo Preencher em letra de forma PERSONAL DATA FULL NAME Data de Nascimento DATE OF BIRTH Dia DAY M s MONTH Ano YEAR Local de Nascimento PLACE OF BIRTH Sexo SEX Altura p s HEIGHT Masculino MALE UF STATE Pa s de Nascimento COUNTRY OF BIRTH Profiss o ou Ocupa o principal PROFESSION OR MAIN OCCUPATION Feminino FEMALE Estado Civil MARITAL STATUS Solteiro a SINGLE Casado a Divorciado a MARRIED Vi vo a DIVORCED WIDOWED Separado a Judicialmente LEGALLY SEPARATED 2 - ENDERE O PARA CONTATO CONTACT ADDRESS Cidade Estado CITY Zona Postal Pa s ZIP CODE Telefone E-mail COUNTRY TELEPHONE Nome da pessoa para contato Endere o Parentesco/Rela o PERSON S NAME RELATIONSHIP TO APPLICANT STREET ADDRESS 5 - TERMO DE RESPONSABILIDADE Assinatura FORMAL STATEMENT SIGNATURE Declaro serem verdadeiras e completas as informa es contidas no presente documento. I declare that the above information is true and accurate. Local PLACE Dia DAY Data DATE NOTA Os dados constantes deste formul rio s o para uso exclusivo da Reparti o consular e n o ser o divulgados para institui es p blicas ou particulares. 6 - AUTORIZA O PARA EMISS O DA CMC PARA MENOR AUTHORIZATION TO ISSUE A CONSULAR ID CARD TO MINORS Autorizamos o Consulado-Geral do Brasil em Miamii a emitir a carteira de matricula consular para o a nosso a filho a menor identificado a neste formul rio. We hereby authorize the Consulate General of Brazil in Miami to issue a consular ID card to our child identified in this form* Assinatura do Pai FATHER S SIGNATURE Passaporte PASSPORT N mero NUMBER rg o Expedidor ISSUED BY Data de Expedi o ISSUED ON M s ISSUED ON Revisado em jul/2009. brazilmiami. org Email registros brazilmiami. org 1 - DADOS PESSOAIS Nome Completo Preencher em letra de forma PERSONAL DATA FULL NAME Data de Nascimento DATE OF BIRTH Dia DAY M s MONTH Ano YEAR Local de Nascimento PLACE OF BIRTH Sexo SEX Altura p s HEIGHT Masculino MALE UF STATE Pa s de Nascimento COUNTRY OF BIRTH Profiss o ou Ocupa o principal PROFESSION OR MAIN OCCUPATION Feminino FEMALE Estado Civil MARITAL STATUS Solteiro a SINGLE Casado a Divorciado a MARRIED Vi vo a DIVORCED WIDOWED Separado a Judicialmente LEGALLY SEPARATED 2 - ENDERE O PARA CONTATO CONTACT ADDRESS Cidade Estado CITY Zona Postal Pa s ZIP CODE Telefone E-mail COUNTRY TELEPHONE Nome da pessoa para contato Endere o Parentesco/Rela o PERSON S NAME RELATIONSHIP TO APPLICANT STREET ADDRESS 5 - TERMO DE RESPONSABILIDADE Assinatura FORMAL STATEMENT SIGNATURE Declaro serem verdadeiras e completas as informa es contidas no presente documento. I declare that the above information is true and accurate. Local PLACE Dia DAY Data DATE NOTA Os dados constantes deste formul rio s o para uso exclusivo da Reparti o consular e n o ser o divulgados para institui es p blicas ou particulares.

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