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Had been granted a work permit No.

Issued at (Changwat)

1UtJ11t\J1(91'V11\11'U1J\J~U'U to'U'VI
.""1..,

1"'..,.J Vll'U'Vl

..

Present work permit

tl tJ

n1Vf~ (~\I'II!')'~ )
Information

No.

Date of issue

;;

:.;

'W~

: ,; .:..

;; .. :-;

..

Place of issue (Changwat)

Application

Apply for a work permit

tJ ';i~tfl 'VI\I1'U'VIUtl tJ11flJ1(91 '

Category of work being applied

.J

..

~ n'tlru~'11U
Nature of work in detail

1PI1tt lU\lVl'W1'V1/tll'U'Wn'Ul'U'W V
Ti,tte / Occupation / Profession

Vd

cI

eI

.. .
.

'Utl'W1CJ"ill\1
Name of employer

'VItl~ . . (l'W'W
Thanon

La'U'VI

Vl~'VI/tl1fll';i
Moo/Building

Id

'11~tJ
Soi

. .. .. . ..
• ~

Address No.

I'i'Tua/bL'U1\1
TambonlKhwaeng

el1b.fltJ/b'U(9I
AmphoeIKhet
:1.Vl';if'l'WVl •.J
~ -.. ~

"il\lVlll'l

..,

...

';iVlG'l u';i'j3WtJ L
0 •

-..~.I

or

LVl';ii:'i1';i

Changwat
.J

?I(l1'W'VIVl1~1'W'lltJ\lA'W(9Il\11'l11bo'UVl
Place of work No.

v..l

Postcode

Telephone

Facsimile

Vi\j'VI/alAl';i
Moo/Building

'lftlU
50i

(l'W'W
Thanon

1'i'ltJ[j/bL 'Ul\1
TambonIKhwaeng

~lL.fltl/b 'll1Pl
Amphoe/Khet
~

'OJ'IVlll'l
Changwat

..,

._,

';iVl?l..-u';i'j3·WtJ
Postcode

OJ

~.I

d~

L'V1';jrl~'V1

-..

t,Vl';i?il';i

Telephone

F<3csimile

{';j~UG'lm'W~'Vll\11'U \

{{lihJ1nfl11V1~\I

LL ~\I)

{In the case where there are more than one place of work, please specify atl)

3.2 0 "il€lVleltl1~· lUtl11t\J1V1Vi1\11tJ

I 0

_......... ..
Year{5)
d ...,

tJ

_Ll'lelU "ilt.!{;1\11UVl to
.:J

1'U
-Day{s)

~y
..,

for a renewal of a work permit for

lev.:J

. Month{s)

V]\I{.L{;ll'WVl from

3.3

'UeJ-rU1UlbWU1ueJ'4'1!1(9lvhnw
Apply for a substitute of a work permit

f1'Jrul~t.!~1U.
Damage

l~tJ~1tJ ~'1!~1tJ

dJeJ1'LJVi llJeJ1'LJVi 'J'LJ'Vl .: .;

Q.J

. .
d

o
IJ

Date of the ~amage,

mru~HU,;,1tJ 'U
Q.J._:_-_

Lost

bb~.:Jfl111Jb~'U'V1 ru

cJ"

Date of the lost occurred

:..: : .

:;

..
,.::\~,i:;'· ~

Police daily record No,

Date of issue

~fl1iJI'l1'j'J~·:.~.:.::::

At police station

3.4

'Um tl~~'U~~m~~tl'J~U1'V1V1~eJ~

n~ru~,n'LJ

Apply for changeor addition of categoryof work or natureof work

o o

btl~tI'LJtl'J~bfl'V1.:J1'LJ / ~n~ru~.:J1'LJ
To change category of work / nature of work

b~&J'lh~b.f1'Vl.:J1'LJ / ~n~ru~.:J1'LJ
To add category of work / nature of work

(1) tl'J~b.f1'Vl~1'LJ1 Vll.l

New category of work

(2)

«f1~ru~.:J1'LJ 1 VI~
New nature of work

.• -(1.

Reason(s)for change or addition of category or nature of work

........................... -.........••....... ~
3.5

"Umtl~tI'LJVI~m

~1J'LJ1tJ..ij1.:J

Apply for changeor addition of an employer

btl~tI'I.J'LJ1tJ..ij1.:J
To change employer

o bVlUlJ1tJ~1.:J
cJ. d

...

To add employer

-(1) ~eJ'lJ1tJ..ij1~1 VI~

Name of the new employer

.
.• d

'YIeJ~t!;l'lJ'Vl
Address No.

VI~'Vl/eJ1f11'J
MoolBuRding

'I1eJ't!
Sol

; ~

. . ..

{l'U'U
Thanon

1'l1U{;l/V. 'lJ'J.:J
TambonlKhwaeng
....

ei1t.f1eJ/L 'U<'l
AmphoelKhet
'i

~~Vi1~
Changwat

OJ

~'VIi'I\u')\!KUtI Postcode

OJ

~.f

""',.

~'Vl~l"I'V'l'Vl:

OJ"

~'Vl~i'l1'J Facsimile

Reasonis) for change or addition of an employer

.............................................................................................................................................................
•••••••••••• #0

.
, ' .

3.6

'{jmtJ~cJ'UVl~m~lJvrB~~Vl~m"lmu~'Vhnu Apply for changeor addition of locality of work or place of work

o bt1mJ'U'VIB~'VI'V11~1'U-"m'U'VI'VI1~1'U 1
cJ
IJ

cJ

cJ

To change locality of work / place of work

ob 'V'IlJ'VIB~'VI'V11~1'U / G'fm'U'VI'VI1~1'U
To add tocallty of work / place of work

c!

SJ

do"

--~..:

".. do.

*f1'Hl1f11'HtI~CJ'UVl~m~lJVlB~~vh~1'U1-MmBf1~~
- In case of applying {6r:change or addltion oflocallty

(1) uae (2)

of work, please complete both (1) and (2)

(1) VIB.:I vi'1.:11 1VI:J_ _ 'U

New locality of work

vi

" __

~.~: _ ; .._ ._

_.,

_..: : .

':.:.:::

_.._

:.

(2) G'fm'U~vi'1~1'U1Vll.l
New place of work

b~'{j'VI
Place of work No.

cJ

_ _.._ _ _ _

VI~'VI/B1f111
Moo/Building

,CJ

_
_ _

61JB tJ
Soi , eJ1bflB/b "ll1Pl AmphoelKhet
'i b'VI';i"1~

. _ _ . .

f1'U'U
Thanon

_.~1tl~/bb "llJ~

'iJ~VlJIPl
Changwat

viti ..... ~VlG'f ';i'l!truCl

Postcode

TambonlKhwaeng
'i ....... b'VI1f'1'V'1'V1

Telephone

Facsimile

(1~tlG'fm'U~vi'1~1'U

(In the case where there are more than one place of work, please specify all)

{i'1ij~.J1f1f111V1~~bbvi~)

(3)

~~;~~i~·~~~~~·~~~~·~·;~~·~~·~~~~~·~~~;~~·~~·~~~-~ _ .
,
Reason(s)for change or addition of locality of work or place of work
...-

3.7

'lImtl~t:J'UVI~m~lJb~B'Ul"ll
Apply for changeor addition of conditions

o btl~CI'Ul1B'Ul'{j o L~Ul~tl'Ul"ll

To change conditions of work

To add conditions of work

(1) b~B'Uhm.ru
New conditions of work

~2)

~;·;-~~i~~~;~~~~~~·~·~~~~~·~a~~l~·········_ _ . ..·· _ __ ·.······ . .. _ .. _

,
Reason(s) for-change or addition of work~ conditions

5
Documents and Evidences

Together with this application, I have attached herewith the following documents and evidences:

4.1

n~ru~'UA1"lJa~'U1'Ua1iqJ1\9l'vh~1'U fl1"IJal9iaa1~1'Ua1iqJ1\?l lb~~rl1"IJmtJ~EJ'UlbtJ~.:I~1fJn1~1'U1'Ua1iqJ1\9l

In case of Application for a work permit, Application for a renewal of a work permit, and Application for change of items in work permit.

(1)

0
" O~1

~1b'U1U\9l~t1~~~1~1f1'U~lJhin~~"ll1~1vltJ 'VI~a
Copy of Identification card of Non - Thai Nationality, or<

b 'U1bamn1'VJ~b UEJ'UtJ~:rr~\:il1mhun'VJ~ UEJ'UB1 b b[)a'VI~m:h:un'VJ~b tJ'UVf8~ U ~'Ll~~aa nvl11Jn!l'VI1J1 J E 11\9l1tJm~'VI~b 'UtJ'U~1'1!f!l~ 'VI~a
f

I.f

c.I

t:::!l

o o o

Copy of registration record from District or Local RegistrationOffice issued under the law on Registrationof inhabitants, or

6'\'1 'U1 b bafl~1~-r'U~f)~~1EJ ~'VJ~b m utJ'UtJ~~1~hl1n~1i(n'V1~b UmJ81b[)H'VI~a6'\'1'Un'VI~ b umJVfa~ ~'U' , . ;~aanIPl11Jn!l'VI1J1E.d1~1tJf11~'V1~b UtJ'U~1'1!f!l~
.

Copy of certificate of registration record from District or Local Registration Office issued under the law on Registration of inhabitants.

(2)

1'U-r'U~a~"lJa~~tJ~~na'U1"ll1:U'V'lb1"llm~1Jl'111Jn!l'VI&J1cd1~1tJ1"ll1:U'Wb1"llm~1J \J1n~m'U'l"m1'U1~vi-r'U~a~-J1 cr~'Url1"lJa hJm ~f1vi'a ~-X 11J1Pl11J~ -r:01J'U\9l m~m~ 'VI 1~~151 ~ru~"lJtJ~~m 1"1rl1'V1'U ~11 ~ \9l ~ ~ ,
Certificate of a medical practitioner under the law on medical treatment professional from medical services specifying that the applicant is free from any prohibited diseasesas publicated by the Ministry of Public Health.

(3)

'VI'l!~ a-r'U~a~m~~1~'lJa~~~~\J~btJ'U'U1fJ~1~ ~ l(9W~~'U'VI\9lt:J~~hJ~1~, b 1\ 'Uflfl~«ru"ll1~1 'VltJvi1~1'U " ,

IIU

'W~a1J~~'VI"'nj11'UtJ~~na'Ub'VIVlt:J~~~m:i11
Work recbmmendation of a prospectiveemployer describing reasonsfor not employing a person of Thai nationalityto work, together vvith supportingevidences.

(4) , {5) (6)

0 0

6'hl'U1'V1u~~aa1iqj1\9l1~fl'U19i1~~118an'Uam"lJl'1~~'VI'~\9l~1~vi1'V1~butJ'UtJ~~~
Copy of leave for an alien to depart from the Chong'NOt of registration record.

bbtJ'U~bb~\9l~~m'U~vr~"llm~m'U~vi1~1'Uvi"lJmtJ~EJ'U'VI~mvi&J
Map showing the changed or added location of place of work as specified in the application.

n-aw 'U1tJ:5'1.:1 , f1a 5'~~1J\9l1 L th,J'Ufl

In case the employer is a Natural Person

ft1L'U1Ul'1~tJ~~:ij1~1th~"ll1"ll'Ubbm:"'1L 'U1'V1~1 titJ'UU1'U'lJa~~~~\J~L 'U'U1~~\~ 'VI~a U

Copies of Identification card and house registration of a prospective employer, or

~1t 'U1'V1i(~5mVl'U'VI1~"lJaIJ~~IJ\J~L iJ'U'U'W~1IJ 'VI~a

Copy of Passport of a prospective employer, or

ft1L'U1t'Ui1Af1I~'Uvia ~"lJaIJ~~IJ,;)~b U'U'U1{J:ij1IJ ~ ~

Copy of Certificate,of permanent residence of a prospective employer.

.~

n-aw'U1v:5'1.:1LUUU~'llflf1~

In case the employer is a Juristic Person

i1t 'U1tam;11~-r'U~a.:l"lJa.:l?i11411"(1m~vf~~n.u €lIJV"~~.:I-Jln\Jm~"lJ€l.:l~~-3 1~'t~\J\9l'VJ~tUUW ~ \J~tU'U'U1~:ij 'VI~€ll~~'U€l'UtlJ1~v.~\9l~~tt~~i9l1tiJ'U.:I1'Ul\9l{J{] n~{)IJ~11Jfif'lVt1J1~tl9lmt?l\9lIJ'lh::b[)'VIn\lm~ ~1{J ,~ ~ dJ

Copy of certificate of-a relevant (iovernment agency stating the business of a prospective employer has l~alty been 're~istered or granted a license to establish and operate, and the type of business has been spocifJed.

{7) (8)

o o

~tkheJ 'ti'U1Vlen ~
.J.J~

X ~ '011. 1ii1'U1\J-«I ~tl ~

.Jo

:3 Photos<size :3 x 4 cm.)

Lt.tJ'U~Vb?lVl,:j'VI~'1~8-3"'mU'VI'VI1-31'U
Map showing the location of place of work.

(9)
Work Permit (In case of Application for a renewal of a work permit or Application for change of items in work perrnit.)

4.2

n~ru~w;h"UeJ~'Ul'Ubbwul'UeJ'Uru1191

OJ

In case of Application for a substitute of a work permit

(1)

1'UeJ'Uru1191~b~(JVllCJ "
Cl.I

o
(2)

Damaged Work Permit, or

Vl~eJ
i.I ':~-.~ 0

'VI (1mil'll n111'Ubb "J-:Jfl'll~'lJfl-:J b"JTV'J'U n-:Jl'Ul9ll':i'l"J

Police daily record

...

cv

2J

D'

~tlcl1CJ 'lJ'U1~ sn X ~ 'lI~. ~1'U'l'U

\I -.

H.-:' .. <.. '" ;

~tJ

., c,

3 Photos (size 3 x 4 cm.)

-u1'V'1b~1'lJfl~'U1fl-:Jil-U

flfl'll~-Ul-:J

I9l'UbtJ'U"J~-:J'Vlmlsems ,

I hereby certify that the information given above is true in every respect.

(11 CJ~fl"ufl .
Sisnature

1'UVi
Date

tl(J'Ufll'lJ 8 ~
Applicant

..,d

7
bQ 'W 1 ::;Vill Vl'UTVI
FOR OFFICIAL USE ONLY
v v ~

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be:Jf1?ll~bb'l~VlG'lmil'Wm'Um'W 0.51 --;

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be:Jf1?ll sua ~Vi~ n:Ol'W 111fl~'Ull'JtJ

........._._._ . ;

.......................................................................................................................................................
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·..···········:r·································· ..····

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~ 1 CJ~ e:J"I18 1911bbViU~

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u UU1 ..U\l61€)'JU'J€)\l n1'J:V1\l f

FORM OF EMPLOYMENT CERTIFICATION

CVdCV

2/

1. ,jBU"'U1~:ii1<l EMPLOYER'S
1.1
4l:'>""'"

"0 tJ(PlUflfl~j,i~tI ~V1'V1~LUtltJLlJB d .

,
101.

INFORMATION ; ~
.. .;" , _~ ..
_._

oU o

THAI JURISTICPERSON REGISTERED ON:"'-"('

.....•............................... 'V1u:ilVl'V1~lUCJtJ1i11~w.=n ;.................•.........U1'V1 ~ Lfl'1111 NO. PAID-UP CAPITAL .' BATH U1l1 BAHT

.J

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~'l!AfI ~A1-l~11 ~ (ilVl~L UCJtJLriB .~.::~.:.::::.~: ..;:..••...•• ~ltJ1tJL~tJvhl1 LoU1lJ1v1nA 1-l'\.J:i~Vlf'I.•......•..•...:..•: ,=,,~"' L FORIEN JURISTIC PERSON REGISTERED ON"'" THE AMOUNT OF MONEY IMPORTATION ..•. . . tlA fl flli:i:ilJ (il1·iJfI :i'\.J:i ~'lf1'lftJL~'11~::":~::;:i;:; .. NATUAAL PERSON.ID.CARDNO. .•.
~-._..

I~P~i~~
., •

Jlunu ru1f1l11-:J 1'UL~'lJ~ ..••..•.::..••.•.•::•..•........•.......••.•.. :

WORK PERMIT NO. ~
..--~';A'>.' .'" -

~tltJ1CJ:lJ\:j/~mtJth~ntltln1:i ~~'l"'mtJ'\.J1~ntltlfl1:i

NAME OF EMPL;Y~R; ,.:;;, ..

AODRESS

,·.;:~·tr~::
:.::·::·;.::::· ;
.-••.••.••• ~~-

j~:;~~~~:;." ;;
. •~ ", : :'.: ~_

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d3:·.·.·
:.:.:

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.
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" ••••

:L.: :;.~;

...................................................................... ~ .-.;
. lh~LflVln':iJn11 TYPE OF BUSINESS ; :••;.;.;.~.;.:',;;;.;~;~ OF THE ;.~.•~.: ••..
..
•••• ~••••••.•••••••• e.; e•••••••••• ,•." •.••••••••••••••• '

"- .. , ..

r2·iifi1U~\;);iJti;~L1liifiiButJ~~1iii'11 FINANCIAL STATus THE

< .' •• ..

LAST'v&.Ft'"

i:~:-:-:-'

.,: ••••••••••••••• •

.-~•• ~•••••............................................

''':''::::>~-=-.::!'~~:~~'"'-.'' ..~''< '

. ,.;; :U·'W;f'I.. YEAR

i;lJVI~fj6 ASSET

. '7"f_"l~
INCOME

L~tJftWL~tJeJ1nlilJ1A11· . CASH/DEPOSIT

rhh/'illm1U'.1. PROFIT/LOSS'

'. ll1{;hJ~~VI TAX

U 3.mfhn1:ia-ltmn
e'
I

~"."i 71E1 ~I'!u-;u'!tltJ THE RECENTLY INCOME

OJ

U1V1 lJ'il1,:j7::EI::L'l~1 BAHT THE DURATION THE VALUE OF EXPORT U1V1BAHT fltJ PERSON fllJ PERSON" ..
I

L(iltlU--.· . MONTH' .

..

"" 'il1l.J1V1tl-:JL O 1I'!tJ1fltJV11-lth~LVlf'lL",.J,~.J VlEI'l~'U:itlUuVltJ1tJlJ1

'0 iiA'U~h~~1'll11-:JilJ~'lEJt~LL~i:::::.
••••

o
,_

THF. N-AOUNT OF TRAVELLER IMPORT FOR THE LAST YEAR iiwun-:J1 tJAlJl VlEITHE AMOUNT OF THAI WORKERS

D·
.,

2.

;;Ell.Ji'ln1'a~h-3 INFORMATION
., .1 ~.,'

..,,J. 'II1WLv1u:i~ft-:Jfl~::~1-:JfltJV11-:J1'!1'l'iltl I DESIRETO EMPLOY

::::.:.:::".v.1J~.~~~.tL?OD GROUP
.J
v~ )

..

••:•••••ltJ L'Utl~cy1V1l11~11iL~'iI~ f ••••••• ~ :.::: : ~ THE AMOUNT OF WORK PERMIT HOLDERS WORK PERMIT NO. v"" ~ltJ'ltJVlmL sau THE AMOUNT OF ROOMS Vltl-:JROOMS ~1'U'ltJtJm7E1'U THE AMOUNT OF STUDENTS

~: :••.•••.::••••.• : ; fltJ PERSON ...._o-.~ .. ,

., -

.,

o·

Po'

• '_'.

••

•• - •••••

,._.

••••

OF EMPLOYMENT

:•••••••••• ~, "., .•=:..~ .

.

..~qJ'lI1~ NA~~r.rv~
VltlEl1. 'U·J:i~L VlMiVIti ADDRESS LWtlVl1~llJ \u7~LflVl-:J1'UVI'iltl7U\tltl~fY1V1 TO PERFORM(TYPE OF JOB) V11L1.VI'U-lVllJ1V1 I m'ilw ftflllJVlVll~llJ'iltl~fll~~l'l
.10

:'.:/:, ..
. . . . ...

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"0

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-=I

I 'l'lf111WPOSITION /
PLACE OF OORK.
•

Clll/lill

OCCUPAIDN / PROFESSION

trn1!K'ol~-:J1lJOB DESCRIPTION J
.J • ...,

{'a:'lftCl1lJVlVI1-:JllJ Cl1mnm1V1lJ-:JLLVI-:J SPECIFYPLACE OF v.oRK IF MORE THAN ONE PLACE) TO

..,

.1-

".i~EJ::L nl".i~l-:J 'l51 PERlOOOF CONTRAcr

..., d ~ .., .., tI!!l

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YfAR

.tl'ltllJ MONTH

tI!!l

fll1ill-:JV.7tl:ilE1lVl 'ltJa:: I tl'ltl'U5~ WAGE OR INCOME PER DAY / MONTH 7~~u017Pimn~-:J'lV1 THE HIGHEST EOlY"J.TION

'ltJ l.Jft'l!fY1~1-:JCH'ltJVI DAY CONTRACT VAliD UN11~ I ~tdI..., U1V1rJau:i~ UlItJtllJ 'llJa~ I LVltllJ~:: BAHT OTHER BENEFITPER DAY / MONTH
•

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1I/IilI..,

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d..,,,J

. tl1V1 BAHT

-'I

tJ".i~ftun17ruvil-:J1'U JOB EXPERIENCE THE REASON WHY NOT

ftCl1lJll1W YfAR STATUS PtRSON

tJ

0 tal'! 0 ftlJ".i~
SINGlE MARRIED

• .'3.

1't~(Ol~~~1u..ijl~UflR(;lfiru1l1~ll'lat{Jl'h~llJ

,.,

"-0 HIRE THAI

fI~W..•...•....•..•.•....................•.....•.....•.......•...... lJW~l,:j SIGN fMPt..()'lt:fl

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'lUVl DATE.••••••••••••••••••••••••••••••••••••••••••••••••••••••••

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