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Email*
Password*
Name*
Sex*
Date of birth*
Nationality*
Marital status*
What is your occupation*
Line or WhatsApp ID
Passport number*
Passport Expiry date*
Arrival date*
Seat no.
Can we know if you arrival date is confirmed
(ie. you have gotten CoE and flights books) or is it tentative ? *
Which Thai Embassy did you receive your CoE from
(or about to request for a CoE) ?*
Arrival flight / Time *
Card holder name*
Card no*
Type of card*
Expire date (MM/YY)*
Which provice or town do you plan to go
after completing the State Quarantine ?*
Special notes/ requirements
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Your address in Thailand after finishing your quarantine*
Please check to indicate if you have ever had the following conditions*
Surgeries *
Others hospitaliztions *
Have you ever had a blood transfusion ? *
Allergies to medications
Allergies to food
Dietary Restiction
(Ex.Vegetarian and Vegans, Halal, No beef, etc.)
_
What is the name and address of your health insurance company ?
Include street number, city, state and ZIP
Name*
Contact number*
Email*
Note to hotel (Anything you wish to let us know)
Note