Please take your time to fill in the necessary information to complete your request in English only.

Part 1 - Personal Information

Family Name *

Given Names *

Country of Passport

Nationality *

Date of Issue

Date of Expiry

Issuing Authority / Place of Issue as Shown in Passport

Date of Birth

Sex

Male Female

Place of Birth Town / City

Country of Residence / Occupation (where you currently live / work)

Country

Postal Code

Address for Correspondence *

as above

Country

Postal Code

Mobile / Landline Number

- -

Mobile / Landline Number (during official hours)

- -

Fax Number

- -

Part 2 - Travelling Information

Date of Arrival

* Please choose date from calendar.

Date of Departure

* Please choose date from calendar.

Details of Arrangement with a Professional Health Care – Giver / Physician as Proposed for Continued Case.

Carrier

Flight Number

(for Connecting Flight)

Carrier *

Flight Number *

Port of Arrival in Thailand

Do You have any Relatives or Friends in Thailand ?

No Yes

Name of Person

Relationship

Address

Country

Postal Code

Part 3 - Medical Information

Briefly Describe Your Current Medical Treatment Endeavor *

Name / License number of doctor. *

Doctor’s Official Address *

Country

Postal Code

Details of Medical Preparations Add more, if there is more than one medication in requested.

Trade Name	Quantities	Unit	Edit	Delete

During your proposal stay in Thailand, do you expect to news medical costs requiring further medical treatment or follow up?

No Yes

Please provide full detail.

Please provide the attachments to complete the process.

Document Type	file Name	Delete

I certify the following ...

• that the information on this form is complete, correct and up-to-date in every detail.
• that I will abide by the conditions imposed on the permit granted, as well.