aus E rae ar) ™. 8 snuaaygnarianaui an lusifarionsnsan APPLICATION FOR RE-ENTRY PERMIT INTO THE KINGDOM Gout. Written at BR ccm, 4 cg rg . Date Month dou winnudanihfinaanuiniles To tamigration Officer dowwda (uneunarunsena) deans... 7 oie Bema . . bh, Mis, Miss) family name first name Fras... ANG Sees eee AD hnaul, os middle name nationality eae years date of birth fou. a _ovin é - ‘month year changywat avin - shyhuoginuert_ : occupation ‘resent address no. duane. oe EN ONAP een . ‘Tambon/Khwacng “Amphoe/Khet sodureouqnaondudhailursmnndnsin hereby apply for re-entry permit into the kingom Dwtanis Cinnndanitenis single tmoltiple FandbfinranlssaaraUM NLA AMR cece Tintend to g0 to thuuaeaneinizinane Fufh sen... = Teaving Thailand on dae ‘month VAY nt AT nen . = cel by (mode of transportation) for (purpose of visi) and shall retumn asunalnenleano Suh tO. oe sacar PN to Thailand about > date ‘month year ondhiambteiumsteronatiunumbtetumnes hold the passport or travelling document of urea. a ON. " la eter (country) issued at no. dated eu, AA i Share BUT TWA ah HOU ne eer AA. month year valid unl date ‘month year ndtqovnethnilatumsnnsasrrmnisetumadszimn My previous visa for Thailand is of the category of C1 swoydanrn Dvieatin Cruiumein = aur rnon-fmmigrant visa tourist visa transit visa others aarti oh _—titeu., uae PP ono 5 issued at date ‘month year Fonchdumanialseenelmaiie Sut. eu. ‘ noe 1 arrived in Thailand on date ‘month year useléFunygnatho ge AUF nme AAON. : ee Pion ‘and have been permitted (o stay up to daiey month ” year Jondbaodurevhiannadsuudduenadiayndrems Thereby certify that the above statement is true and correct rauansnntutio ‘Your sincerely snuiietoutemuiouifion. es 0 piu Simao igh mb ‘ pplicant sovfiaw 1. duosedoddumnfomoounynmzemaes sun axe 9 Nomice ‘REPLICATION MUST BE MADS IN PERSON photograph 2. fosrmateumsturoaygrn ooo urn shyt sands une 3,00 win fue vdanss axe cm, [APPLICATION FEE IS 000 BAHT PER SINGLE. SAND Soo BAWT Ps MULTIPLE a. Wiiueyywntehifon sclifutumsruieadt [APPLICATION FEE IS NOT REFUNDABLE.For the purpose of | - No... (Additional) Information Form for Foreign National: To Better Serve and Protect ‘This form isto be filled by every alien entering and staying in.the Kingdom of Thailand: and submitted when request any visa ‘or other immigration-retated service Please write clearly in English and enter date of birth in “dd/mmiyyyy(A.D.)” format 1. Foreigner’s Name and Surname & .o Nationality Date Of Bitth rnin Joconnnnnin ABE onnns'¥ea(8) Passport Number. Blood Type . Allergies Name of Hospital currently visit (in Thailand) Last Date of Baty so Port of Entry 2. Foreigner’s Information in Thaitand DAD AddHeSS NO. en Village NO. 8a Road, sonsnnnn Subdistrict, District. Province... sence NO, 2.2 Workplace No. Village NO, nen-SOlnernmnse Subdistrict Distt. Province. 3. Emergency Contact Person(s) 3.1 In Thailand + Name and Surname et ieirncscamcataclonallry si Address No. Village No. eon. Soi Road. District... i = Name and Surname. Addeess No, Distr. sun Road. oe eTel. NO. se —— sonoma 0upation, - Subdistrict Occupation... 1» Subdistrict. Tel. No. . 3.2 In Foreign Country Name anid Sumame sire pee NOROMEY penne OCCUPAEEOL Add 088 NO. non vee Subdistrict os City. Lip Caesarean COONEY, as A Meane of Communication from Official (OPTIONAL) 4.1 FACeb00K ID een 4.3 Email Address 4.2 Line ID. 4.4 Others — 5. Vehicle (IF Avallable) Car/Motoreyele's brand . Model... e201 ees License Plate Number... Provinee. Se Foreigner ce ) svewensovesesetsenenenenseno4se# For Official Only "heseeeenertasessnieesenseeaereetints 1. Information of Recording Person _ Recording Date Lcceseened acest A BODY = Natne and Position of Recording Person (Official or Private) ‘Name and Sumeme..... o Agency 2. Bunk Account Number (Required for Visa Extenston Only) Bank : Branch Account Name es sone Ageount Number Signed ore Recording Person c 7 ) Position Chis form have been modified by the Information Form for Foreign National Working Graup of immigration urea on 18 August 2016)