DSWD-PMB-GF-003 | REV 02 / 30 SEPT 2022

Date: _______________

CONSENT TO TRAVEL
John Vincent Nosis Refuerzo
I/We ___________________________________ Jobelle Bacsal Delos Santos
and ______________________________,
Common Law
of legal age, _______________ (civil status), ________________(nationality),
Filipino and a resident
36 Digos Street Luzviminda Village Batasan Hills Quezon City
of _______________________________________________________, and with tel.
+63282826881
no.___________________.

Sean Neijhelle Delos Santos Refuerzo

I am/We are the father/mother/legal guardian of ________________________________,
________________________________,
N/A N/A
and _________________________________.
Japan
My/Our child/children will travel to _______________________, ____________________,
__________________________, ________________, (country) for the following reason/s
Tourism
_________________________________________________. She/ He/ They will be leaving
November 17, 2023
on _____________________________ and stay in the said country for a period of
_____________________
12 days Ray Kristoffer Nosis Refuerzo
and will be taken care of_______________________________.

I am/we cannot personally travel with my child/children due to the following

Work
reason/s_________________________________________________________. I am/we
are giving my/our full consent for the minor child/children to travel abroad accompanied by
Ray Kristoffer Nosis Refuerzo
____________________________________________, _______________________. I/We
personally guarantee that he/she/they will not in any manner become public ward/s of any
authority of any country he/she/they may happen to pass en route to his/her destination.

John Vincent Nosis Refuerzo Jobelle Bacsal Delos Santos

FATHER MOTHER

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DSWD Field Office X, Masterson Ave., Upper Carmen, Cagayan De Oro City Philippines (9000)
Website: https://fo10.dswd.gov.ph Tel Nos.: (088) 565 5795