ประกาศสำนักงานคณะกรรมการอาหารและยา
เรื่อง การกำหนดแบบคำขอรับใบอนุญาต และใบอนุญาตน้ำยาเสพติดให้โทษหรือวัตถุออกฤทธิ์
ซึ่งต้องใช้รักษาโรคเฉพาะตัวติดตัวเข้ามาในหรือออกไปนอกราชอาณาจักร

พ.ศ. ๒๕๖๗

โดยที่เป็นการสมควรกำหนดแบบคำขอรับใบอนุญาต และใบอนุญาตน้ำยาเสพติดให้โทษ
หรือวัตถุออกฤทธิ์ซึ่งต้องใช้รักษาโรคเฉพาะตัวติดตัวเข้ามาในหรือออกไปนอกราชอาณาจักร เพื่อให้
การกำกับดูแลยาเสพติดให้โทษหรือวัตถุออกฤทธิ์เป็นไปอย่างมีประสิทธิภาพ

อาศัยอำนาจตามความในข้อ ๑๐ แห่งกฎกระทรวงการอนุญาตน้ำยาเสพติดให้โทษหรือวัตถุออกฤทธิ์
ซึ่งต้องใช้รักษาโรคเฉพาะตัวติดตัวเข้ามาในหรือออกไปนอกราชอาณาจักร พ.ศ. ๒๕๖๗ เลขาธิการ อย.
กำหนดแบบคำขอรับใบอนุญาต และใบอนุญาตน้ำยาเสพติดให้โทษหรือวัตถุออกฤทธิ์ซึ่งต้องใช้รักษา
โรคเฉพาะตัวติดตัวเข้ามาในหรือออกไปนอกราชอาณาจักรไว้ ดังต่อไปนี้

ข้อ ๑ ประกาศนี้ให้ใช้บังคับแต่วันถัดจากวันประกาศในราชกิจจานุเบกษาเป็นต้นไป

ข้อ ๒ คำขอรับใบอนุญาตน้ำเยียสาระสพิติดให้โทษหรือวัตถุออกฤทธิ์ ให้ใช้แบบ Form IC-1
ท้ายประกาศนี้

ข้อ ๓ ใบอนุญาตน้ำเยียสาระสพิติดให้โทษหรือวัตถุออกฤทธิ์ ให้ใช้แบบ Form IC-2
ท้ายประกาศนี้

ข้อ ๔ คำขอรับใบอนุญาตล่าสุดของยาเสพติดให้โทษหรือวัตถุออกฤทธิ์ ให้ใช้แบบ Form OC-1
ท้ายประกาศนี้

ข้อ ๕ ใบอนุญาตล่าสุดของยาเสพติดให้โทษหรือวัตถุออกฤทธิ์ ให้ใช้แบบ Form OC-2
ท้ายประกาศนี้

ประกาศณ วันที่ ๒๑ สิงหาคม พ.ศ. ๒๕๖๗
ณรงค์ อภิกูลวนิช
เลขาธิการคณะกรรมการอาหารและยา

# APPLICATION FOR

## AN INBOUND CARRYING BY TRAVELLER UNDER TREATMENT OF MEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OF THE SINGLE CONVENTION ON NARCOMIC 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 name:
   Given names:

2. Name in your own script or character – if applicable

3. Nationality – as shown in your passport

4. Details from your passport
   Passport number:
   Country of Passport:
   Date of issue:
   Day: _______________
   Month: _____________
   Year: ____________
   Date of expiry:
   Day: _______________
   Month: _____________
   Year: ____________

5. Sex ________ Male     _______ Female
   DAY: _______________
   MONTH: _____________
   YEAR: ____________

6. Date of birth
   Town/city: _______________________
   Country: _______________________

7. Place of birth
   Transaction No.: _______________________
   Submitted Date: _______________________

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

Postal Code:

10. Address for correspondence (if different than your residential address, write ‘AS ABOVE’)
Postal Code:

11. Your telephone numbers – where you can be contacted
Country Code Area Code Number
Office hours ( ) ( )
The country code area code and number should be indicated by brackets.
After hours ( ) ( )
The country code area code and number should be indicated by brackets.

12. Do you agree to the department communicating with you by fax, e-mail, or other electronic means?
No ________ Give details Fax number ( ) ( ) E-mail address:
Yes _______ 
Country Code Area Code Number

14. Give details of the doctor in your home country who provided you with medical treatment.

Name and Licence number of doctor:

Address:

Postal Code:

15. Give the expected date of arrival and departure from Thailand and details of arrangement for your continued care in your home country.

Date of arrival:

Day __ Month __ Year __

Date of departure:

Day __ Month __ Year __

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

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 for you 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 insufficient space, attach an additional statement.

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 for you 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 insufficient space, attach an additional statement.

18.Give details of your itineraries

Port of Departure (from your country):

Carrier / Flight number:

Port of Entry (in Thailand):

Carrier / Flight number:

19. Do you have any relatives or friends in Thailand?
☐ No
☐ Yes   ▶Give all relevant details Name of person:
 Relationship:
Permanent resident of Thailand?
☐ No
☐ Yes
 Address:
Postal Code:
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?
☐ No
☐ Yes   ▶Please provide full details.
If insufficient space, attach an additional statement.
Part B – Declaration
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.
The Signatureof applicant:
Date: ____________________

# THE ROYAL THAI GOVERNMENT FOOD AND DRUG ADMINISTRATION

A PERMIT TO CARRY MEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OF THE SINGLE CONVENTION ON NARCOMIC DRUGS, 1961 AND THE CONVENTION ON PSYCHOTROPIC SUBSTANCES, 1971.

## PERMIT No. .... B.E. ...... 

In accordance with the national law relating to the Narcotic Drugs, The Secretary - General of the Food and Drug Administration, being the official charged with the domestic and international controls of medical preparations containing substances under control of the Single Convention on Narcotic Drugs, 1961, and the Convention on Psychotropic Substances, 1971, in Thailand, hereby permitted holder to enter and remain in Thailand with the following medical preparations:

**Permit Holder:** Name .................................................................Passport No. ..............................................................Port of Departure ....................................................Port of Entry ...........................................................

List of medical preparations permitted for not more than ninety days of self-care:

|                      |          |
|----------------------|----------|
|                      |          |
|                      |          |
|                      |          |
|                      |          |
|                      |          |

Date of Issue ___________

Date of Expiry _________
Signature of official

# APPLICATION FOR

## AN OUTBOUND CARRYING BY TRAVELLER UNDER TREATMENT OF MEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OF THE SINGLE CONVENTION ON NARCOMIC 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 name: 
   Given names:

2. Name in your own script or character – if applicable
   
3. Nationality – as shown in your passport
   
4. Details from your passport
      Passport number: 
      Country of Passport: 
      Date of issue: DAY MONTH YEAR: 
      Date of expiry: DAY MONTH YEAR: 
      Issuing authority: 
      Place of issue as shown in your passport: 
      
5. Sex
   Male ☐ Female ☑️
   Date of birth: DAY MONTH YEAR: 
   
7. Place of birth
   Town/city: 
   Country: 
   
8. Country where you live:
   
9. Your current residential address – where you can be contacted
Note: A post office box address is not acceptable as a residential address. Failure to give a residential address will result in your application being invalid.
   
10. Address for correspondence
(If the same as your residential address, write ‘AS ABOVE’.)
   POSTAL CODE
   
11. Your telephone numbers – where you can be contacted
Country Code Area Code Number
Office hours (66) (
After hours (66) (
   
12. Do you agree to the department communicating with you by fax, e-mail, or other electronic means?
   NO ☐
   Yes ☑️ Give details
Fax number (66) ()
e-mail address:
   
13. Briefly describe the medical treatment you have received in Thailand. If insufficient space, attach an additional statement.
   
The ROYAL THAI GOVERNMENT FOOD AND DRUG ADMINISTRATION

Give details of the doctor in Thailand who provided you
with medical treatment.
Name and Licence number of doctor:
Address:
Postal Code:
15 Give the expected date of departure and arrival in
Thailand.
Date of departure:
Date of arrival:
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 for you 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 insufficient space, attach an additional statement.
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 for you 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 insufficient space, attach an additional statement.
18 Give details of your itineraries
Port of departure (from your country):
Carrier / Flight number:
Port of entry (in Thailand):
Carrier / Flight number:
19 Do you have any close relatives or friends in Thailand?
No □
yes □
give all relevant details
Name of person:
Relationship:
Permanent resident of Thailand?
No □
yes □
Address:
Postal Code:
The information on this form is complete,
correct and up-to-date in every detail.
I declare that the information on this form is complete,
correct and up-to-date in every detail.
of applicant
Signature
of applicant
DAY MONTH YEAR
Date

# THE ROYAL THAI GOVERNMENT FOOD AND DRUG ADMINISTRATION

## A PERMIT TO CARRY MEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OF THE SINGLE CONVENTION ON NARCOMIC DRUGS, 1961 AND THE CONVENTION ON PSYCHOTROPIC SUBSTANCES, 1971.

### PERMIT No. .... B.E. ...... 

In accordance with the national law relating to the Narcotic Drugs, The Secretary - General of the Food and Drug Administration, being the official charged with the domestic and international controls of medical preparations containing substances under control of the Single Convention on Narcotic Drugs, 1961 and the Convention on Psychotropic Substances, 1971, in Thailand, hereby permitted holder to carry while overseas travelling the following medical preparations:

**Permit Holder:** Name ................................................................. Passport No. ......................................................
Port of Departure ........................................................................ Port of Entry .......................................................

List of medical preparations permitted for not more than ninety days of self-care:

|                      |          |
|----------------------|----------|
|                      |          |
|                      |          |
|                      |          |
|                      |          |
|                      |          |
|                      |          |
|                      |          |

Date of Issue ___________
Date of Expiry _________
Signature of official