No. _____________ For the purpose of _____________________

Foreign National Information This form shall be used for making record of information of every alien entering and staying in the Kingdom of Thailand and shall be submit with Notification of Residence for Aliens (section 37 , 38 of Immigration Act, B.E. 2522), or 90-days Notification, or Extension of Stays (all purposes), or Re-Entry Permit, or in all cases involving alien labors.

(If any item does not apply, please write “-”) Providing false information to an officer, shall be punished under Penal Code. 1. To be Completed by Recording Person

Recording Agency ________________________ Recording Person Code _______________________ Recording Date ______________________________________________________________________ Name and Position of Recording Person (Official or Private) Name-Surname _____________________________ Position _________________________________ Agency ____________________________________ Telephone _______________________________

2. Alien Information (Please Use Gregorian Calendar Format Day/Month/Year) 2.1. Alien’s Name _________________ Surname _________________ Middle _________________ Nationality _____________

Date of Birth _______ / ________ / _______ Age ________ year(s), Passport Numbers ______________________________ Father’s name/surname ______________________________ Mother’s name/surname ____________________________

2.2. Information on Alien’s Home Country Address No. ______________ Village No. ________________ Soi, Lane ______________ Road _______________________ Sub-district ___________________ District, City ___________________ Region, Province, State ______________________ Country _________________________ Telephone Number _______________ Mobile phone Number ________________ Information of Community Leader (for national of Laos PDR, Cambodia, Myanmar and Vietnam) Name __________________ Surname __________________ Middle __________________ Occupation ________________ Address No. _____________ Village No. ________________ Soi, Lane _______________ Road _______________________ Sub-district ____________________ District, City ____________________ Region, Province, State ____________________ Country _________________________ Telephone Number _______________ Mobile phone Number ________________

2.3. Address in Thailand 2.3.1. Address No. ______________ Village No. _______________ Soi, Lane _______________ Road ___________________

Sub-district _______________________ District, City ______________________ Province _______________________ Telephone Number _______________________________ Mobile phone Number ____________________________

2.3.2. Workplace _________________________ Address No. __________ Village No. ___________ Soi, Lane ____________ Road _______________________ Sub-district _______________________ District, City _____________________ Province ____________________ Telephone Number ______________ Mobile phone Number _________________

2.4. Frequently used Social Media (OPTIONAL-this will be used as additional means of communications from official) 2.4.1. Facebook ___________________________________ 2.4.2. Line ID ____________________________________ 2.4.3. Other _____________________________________ Email Address _____________________________________

2.5. Vehicle Car/Motocycle’s Brand _________________________ Model ______________________ Color _______________________ License Plate Number ___________________________________________________________________________________

SUB - DIV.3, IMM. DIV.1

2.6. Frequently Visited Places or Premises (such as Club, Restaurant, Shop, Hospital etc.) __________________________________________________________________________________________________________________________________________________________________________________________________________

2.7. Emergency Contact Person(s) 2.7.1. Thai Nationality Name ____________________________________________ Surname ___________________________________________ Address No. _______________ Village No. ________________ Soi, Lane _______________ Road ____________________ Sub-district ___________________________ District, City _______________________ Province _____________________ Telephone Number ________________________________ Mobile phone Number _______________________________ Workplace ____________________________________________________________________________________________ Address No. _______________ Village No. ________________ Soi, Lane _______________ Road ____________________ Sub-district ___________________________ District, City _______________________ Province _____________________ Telephone Number ________________________________ Mobile phone Number _______________________________

2.7.2. Foreign Nationality Name ________________________ Surname _______________________ Middle ______________ Nationality _________ Address No. _______________ Village No. ________________ Soi, Lane _______________ Road ____________________ Sub-district ___________________________ District, City _______________________ Province _____________________ Telephone Number ________________________________ Mobile phone Number _______________________________ Workplace ____________________________________________________________________________________________ Address No. _______________ Village No. ________________ Soi, Lane _______________ Road ____________________ Sub-district ___________________________ District, City _______________________ Province _____________________ Telephone Number ________________________________ Mobile phone Number _______________________________

2.8. Bank Account Number (Only required for certain types of visa applications) Bank ______________________ Branch ______________________ Account Name ________________________________ Account Number ______________________________________________________________________________________

Note: Other Details (If Any) ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signed ____________________________ Alien ( ____________________________ ) Signed ____________________________ Interview/Recording Person ( ____________________________ ) Position ____________________________ _______ / _______ / ________