(This Form is Free of Charge) Please afc Pleas affix photograph photograph oe iiten vin faken within the ast month the let month VISA APPLICATION FORM | (3 usm) Gsx43on) Royal Thai Embassy, Vientiane FIM. Mts. Cass, fro ny ung First Name” Middle Name’Brng ‘Family Name/numemns (in CAPITAL letters) Nationality/BuR90, Proposed Address in Thailand Sidingeivaoton Nationality at BirthiSugraco,. : Place of Birth/seM MAAC ae : Marit Statusavqnuvneuio Date of Birth ficFo, § GSovettu d veemotar Passport /Travel Document NoJ cand Place of Issue! cond. Date of Issue! Subieen Date of Expiry’ SunDoong Occupation nu (secty present positon and name of employes) Adaeestn Ln POR de se aro Aaaress in Country o residence desp0e Name Date birth of accompanying etre # eae fifo Boon Date of Arrival in Thailand Sieumy ‘Traveling by/ umagtow.. Duration of Proposed Stay! GARMIN ncn Please Indicate Type of Visa Requested © Diplomatic © Official © Courtesy OTouist. =O Transit = © Non-Immigrant (Please specty purpose of vist), ‘Number of Entries Requested, Tel Yo, Name and Contact of Guarantor in LaoPDR & Gouin Y aed 270. ‘Attention For Tourist and Transit Vise Applicants ‘You declare that the purpose of your visit to Thailand is for pleasure or transit only and that in ni case shall ‘you engage yourself in any profession or occupation ‘while in the country, nue odDucenetntecnidlernnmoseigo nBidhomgon ntiy coxwedtinuuneventy nf ogynto 9 tuswanatn, Thereby declare that I will not request any refund from my paid visa fee even if my application has been declined. Nast: ALL FRES PAID ARE NOT REFUNDABLE ninco : SiuGudnmhyjugnhoed Signature Date FOR OFFICIAL USE/ (swiwaveSousiaih) Staff name, Visa No, 1 Fee ‘Type of Visa: © Diplomatic oficial —_ O Courtesy ONon-Immigrant OQ Yourist — OTra Category of Visa: Q Single © Double © Multiple O___ Entries Date of Issue Expiry Date Remarks. Authorized Signature and seal