Consulate General of the Kingdom of the Netherlands

Authorization

I, ____________________________, herby authorize

Mr. Mrs. Ms. ______________________________, of
__________________________, to submit and collect my
visa application.

I declare that I am fully aware that with my signature on

the visa application form I take responsibility for the
indications in the application form as well as for the
documents submitted.

Further I confirm herewith that my phone number

is____________________, my mobile number
is___________________________ and my email address
is ______________________________________.

Place & Date

______________
(Signature)
Name, Surname, Passport Number