Transaction No. ......................................
Submitted Date .....................................

THE ROYAL THAI GOVERNMENTFOOD AND DRUG ADMINISTRATIONFORMIC - 1

APPLICATION FOR

AN INBOUND CARRYING BY TRAVELLER UNDER TREATMENT OFMEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OFTHE SINGLE CONVENTION ON NARCOTIC DRUGS, 1961
AND THE CONVENTION ON PSYCHOTROPIC SUBSTANCES, 1971.
Part A – Your details
Please complete using BLOCK LETTERS
1 Your full name – as in your passport
Family nameGiven names

9 Your current residential address – where you can be contactedNote: A post office box address is not acceptable as aresidential address. Failure to give a residential address will
result in your application being invalid.

2 Name in your own script or character – if applicable
3Nationality – as shown in your passport

4 Details from your passport
Passport number
Country ofPassport

11 Your telephone numbers – where you can be contacted
COUNTRY CODE AREA CODE

Date of issue
DAY MONTH YEAR

Date of expiry

FemaleDAY MONTH YEAR

6 Date of birth
7 Place of birth
Town/cityCountry

Office hours ()(NUMBER)

COUNTRY CODE AREA CODE

After hours ()(NUMBER)

12 Do you agree to the department communicating with you
by fax, e-mail, or other electronic means?
NOYes►Give details

Issuing authority/
Place of issue asshown in yourpassport
Male

10 Address for correspondence(If the same as your residential address, write 8AS ABOVE9.)

POSTAL CODE

DAY MONTH YEAR

5 Sex

POSTAL CODE

COUNTRY CODE AREA CODE

Fax number(E-mail address)(NUMBER)

13 Briefly describe the medical treatment you have received inyour home country. If insufficient space, attach an additional
statement.

8 Country where you live

Continued on next page ►14 Give details of the doctor in your home country who provided
you with medical treatment.
Name and Licence number of doctor

18 Give details of your itineraries
Port of Departure (from your country)
Carrier / Flight number

Address

Port of Entry (in Thailand)
Carrier / Flight number
POSTAL CODE

15 Give the expected date of arrival and departure fromThailand and details of arrangement for your continued
care in your home country.
DAY MONTH YEAR

19 Do you have any relatives or friends in Thailand?
NOYes►Give all relevant details
Name of person

Date of arrival
DAY MONTH YEAR

Date of departure
Details of arrangement. If insufficient space, attach
an additional statement

Relationship
Permanent resident of Thailand?
NOYes
Address

POSTAL CODE

16 Give details of the medical preparations containing substances
under control of the Single Convention on Narcotic Drugs,
1961, which the doctor in your home country arranged foryou during your stay in Thailand. (For amounts not exceeding
90 days of treatment)
Details of medical preparations (Trade name, generic name,strength, instruction for use and total quantity). If insufficientspace, attach an additional statement.

20 During your proposed stay in Thailand, do you have or
expect to incur medical costs or require treatment or
medical follow up for your medical condition?
NOYes►Please provide full details.
If insufficient space, attach an additional statement.

Part B – Declaration
17 Give details of the medical preparations containing substances
under control of the Convention on Psychotropic Substances,
1971, which the doctor in your home country arranged foryou during your stay in Thailand. (For amounts more than
30 days and not exceeding 90 days of treatment)
Details of medical preparations (Trade name, generic name,strength, instruction for use and total quantity). If insufficientspace, attach an additional statement.

21 Applicant
I declare that the information on this form is complete,correct and up-to-date in every detail.
I will abide by the condition imposed on the permit
granted.
Signatureof applicant
DAY MONTH YEAR

Date