(TRANSLATION)

Official Emblem
BIRTH CERTIFICATE
Thor Ror.19, Part 2
Registration Office: No.:
1. 1.1 Name: Surname: 1.2 Sex: 1.3 Nationality:
The [ ] Male [ ] Female Thai
Newborn 1.4 Date of Birth: Time Corresponding to the Day: Lunar Month Year of the
hrs. [ ] Waxing Moon: [ ] Waning Moon:
1.5 Place of Birth: House No., Village No., Alley, Road Sub-district, District, Province : Country:

2.Mother 2.1 Name: Maiden Name: 2.2 Age: 2.3 Nationality:

years
2.4 Residing at the Same House No. , Village No. , Alley, Road, Sub-district, District, Province :
Place as the Newborn:
3.Father 3.1 Name: Surname: 3.2 Age: 3.3 Nationality:
. years
4.. Birth 4.1 Name: Surname: 4.2 Residing at House No., Village No. , Alley, Road, Sub-district, District, Province
Notifying .
Person 4.3 Relationship: 4.4 Signature of Birth Notifying Person: -signature-
[ ] Head of Household [ ] Father [ ] Mother
[ ] Officer [ ] Birth Delivery Person [ ] Other
5. Date of Birth Notification : 6. Date of Name Change Notification : Day / Month / Year
7. Signature of Birth Acknowledging Registrar: 8. Signature of Name Change Acknowledging Registrar:

.............-signature-.................. …………-signature-………………
( …………………….) ( )
Registrar …………………………………… Registrar………………………………..

Certified Correct Translation