For the purpose of No

(Additional) Information Form for Foreign National To Better Serve and Protect This form is to be fill ed by every al ien entering and staying in the Kingdom of Thailand and submitted when request any visa

or other immigration-related service Please write clearly in English and enter date of birth in middotddlmmyyyy(A D) format

1 FOIeigners Name and Surname Nationality

Date of Birth I Age Y~(s) Passport Nwnber

Blood Type Allergies

Name of Hospital currently visit (in Thailand)

Last Date of Entry Port of Entry

2 Foreigners Information in Thailand 21 Address No Village No Soi Road Subdistrict

DistricL Province Tel No

22 Workplace No Village No Soi Road

Subdistrict District Province Tel No

3 Emergency Contact Person(s) 31 In Thailand - Name and Surname Nationality Occupation

Address No Village No Soi Road Subdistrict

District Province Tel No

- Name and Surname Nationality _ Occupation

Address No Yillage No soi Road Subdistrict

District Province Tel No

32 In Foreign Country Name and Surname Nationality Occupation

Address No Road Su~district City

Zip Code Country Tel No

4 Social Media as A Means of Communication from Official (OPTIONAL) 41 Facebook lD _ 43 Email Address

42 Line lD 44 Others

5 Vehicle (IF Available) CarMotorcycles brand ModeL Color

License Plate Number Province

Signed Foreigner

( )

-- 1

For Official Only

1 Information of Recording Person - Recording Date I t Agency

- Name and Position of Recording Person (Official or Private)

Name and Surname Position

Agency TeL No

2 Bank Account Number (Required for Visa Extension Only) Bank middotBranch

Account Na~ Account Number

Signed Recording Person

( )

Position

(This form have been modified by the Information Form for Foreign National Working Group of Immigration Bureau on 18 August 2016 )