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