Form Qt-2 - Travel Consent Form Page 2
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2________________________
________________________
ADDRESS
ADDRESS
DIRECCIÓN
DIRECCIÓN
________________________
________________________
PHONE NUMBER
PHONE NUMBER
NÚMERO DE TELÉFONO
NÚMERO DE TELÉFONO
_________________________
________________________
ALTERNATIVE PHONE NUMBER
ALTERNATIVE PHONE NUMBER
NÚMERO DE TELÉFONO ALTERNO
NÚMERO DE TELÉFONO ALTERNO
Signed this ____________ day of ____________, _____.
Firma este
DIA
día de
mes
año.
_________________________
________________________
SIGNATURE
SIGNATURE
FIRMA
FIRMA
ACKNOWLEDGEMENT OF NOTARY PUBLIC
State of ____________
)
)
ss.
County of _______________
)
On the ____ day of _____________, _____ before me, the undersigned, a Notary Public in and for said
State, personally appeared _______________, personally known to me or proved to me on the basis of
satisfactory evidence to be the individual whose name is subscribed to the within instrument and
acknowledged to me that he or she executed the same in his or her capacity, and that by his or her
signature on the instrument, the individual, or the entity upon behalf of which the individual acted,
executed the instrument.
_____________________
Notary Public for the State of _______________
My commission expires: ______________
DECLARACIÓN NOTARIAL
En el Estado ____________
)
)
ss.
En el Condado _______________
)
El día ___ del ____, ___ ante mí, el suscrito, Notario Público del Estado antes mencionado,
personalmente compareció ______________, al cual conozco personalmente o acreditó ante mí su
personalidad satisfactoriamente, así como su capacidad legal para firmar el presente instrumento y
ratifica la firma del mismo.
_____________________
Notario Público del Estado de _______________
Mi comisión expira el: ______________
QT-2 (Rev 1/14) Page 2
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