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FORM FOR A NOTARY PUBLIC TO NOTARIZE AN APPLICANT'S SIGNATURE

Instructions for an applicant : Please take this form to a notary public; fill out and sign the form before the notary public and have the notary public notarize your signatures, and then return the form along with your application to "The Royal Thai Embassy (Consular Section), Room 101, 1024 Wisconsin Avenue, N.W., Washington, D.C. 20007" For further inquiries, call (202) 944 3600. I, the applicant whose name appears below, hereby provide my notarized specimen signatures hereunder both in Thai and in English before the undersigned notary public as required by the Embassy's regulations to accompany my application for a Thai passport/ Power of Attorney and/or Letter of Consent. Applicant's name : (In Thai)......................................................................................

(In English)......................................................................................

Address : .........................................................................................................................

....................................................................................................................

Phone Number : (..............) ..........................................................................................

Application's signature in Thai : ....................................................................................

Application's signature in English : .................................................................................

For Notary Public's Use Only

Subscribed and sworn to and before me, a Notary Public in and for County of.............................. , State of .............................. , on this .................................... day of ............................ In the year of .................................

(Signed) ......................................................................... (.......................................................................) Notary Public My commission expires on : .................................................................................................................... My address : .............................................................................................................................................. ....................................................................................................................................... Phone Number : (..............) ..........................................................................................

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