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FORM IC - 1 THE ROYAL THAI GOVERNMENT FOOD AND DRUG ADMINISTRATION APPLICATION FOR AN INBOUND CARRYING BY TRAVELLER UNDER TREATMENT OF MEDICAL PREPARATIONS CONTAINING SUBSTANCES UNDER CONTROL OF THE SINGLE CONVENTION ON NARCOTIC DRUGS 1961. 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 Nationality as shown in your passport Date of expiry Male 6 Date of birth 7 Place of birth Town/city Country 10 Address for correspondence If the same as your residential address write AS ABOVE. 11 Your telephone numbers where you can be contacted COUNTRY CODE AREA CODE DAY MONTH YEAR Office hours After hours NUMBER 12 Do you agree to the department communicating with you by fax e-mail or other electronic means NO Give details Yes Issuing authority/ Place of issue as shown in your passport 5 Sex POSTAL CODE 4 Details from your passport Passport number Date of issue 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* Female Fax number E-mail address 13 Briefly describe the medical treatment you have received in your home country. If insufficient space attach an additional statement. 8 Country where you live Continued on next page you with medical treatment. Name and Licence number of doctor. Address 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 Disembarkation Port Carrier / Flight number 18 Do you have any relatives or friends in Thailand Give all relevant details Name of person Relationship Permanent resident of Thailand Date of departure Details of arrangement. If insufficient space attach an additional statement 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 30 days of treatment Details of medical preparations Trade name generic name strength and quantity. If insufficient space attach an 19 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 Please provide full details. If insufficient space attach an additional statement. Part B Declaration 20 Applicant I declare that the information on this form is complete correct and up-to-date in every detail* Embarkation Port I will abide by the condition imposed on the permit granted* Signature of applicant Date. 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 Nationality as shown in your passport Date of expiry Male 6 Date of birth 7 Place of birth Town/city Country 10 Address for correspondence If the same as your residential address write AS ABOVE. 11 Your telephone numbers where you can be contacted COUNTRY CODE AREA CODE DAY MONTH YEAR Office hours After hours NUMBER 12 Do you agree to the department communicating with you by fax e-mail or other electronic means NO Give details Yes Issuing authority/ Place of issue as shown in your passport 5 Sex POSTAL CODE 4 Details from your passport Passport number Date of issue 9 Your current residential address where you can be contacted Note A post office box address is not acceptable as a residential address. .