Vize bagvurumun ............

isimli gahrs tarafrndan yaprlmasrna izin veriyorum, yukartda ismi gegen gahsrn veya

ilgili/ba!lantrlr olduIu acentanrn, ttalya BagkonsolosluIu ile baglantrlrveya anla5malr

olmadrirnrn bilincindeyim NOT:Yetkilendirilen ki5inin T.C,Kimlik No yazrh 1 ad.Niifus Crizdanr(kimlik)fotokopisigetirilmelidir.

Ta

rih:

isim:
Soyadr:

Pasaport numarast:
imza:

,, I
e6-i:-rii:111"'8"-r'-

I hereby authorise....:r...--.r....:.,...... .."..........................,..................:............

"to'halt'fEmy'ffia'"app'liCatftll. tamaware;thatneitherthe above mentioned person, northe

agent he/she is employed by, has any agreement or connection with the Consulate Generalof

the

lta ly.

P,C.;The copy of TR ldentity card (with identity number mentioned on it) of the authorized person

'

must be inside the applicant file.

Date: Name:

Surname:
Passport number:
Signat
u

re: