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Notes

Cursive fields are required fields
Please fill out as much data as possible
Information you cannot put into any other field goes into the comment field at the end of the form

Your advantages with the IKS member card:

IKS member card: 1000,00 THB valid 2 years
Receive all advantages of our Members for Members program (IKS members give you discounts on their products or services)
monthly info meeting
Red Cross 24 hours info service (information of ambulance and hospitals about your medical data and information of relatives in case of emergency)
more advantages to come...

Personal Data Family Name Given Name Date of birth (YYYY-MM-DD) Place of birth Gender

male female

Nationality Occupation

Contact Data Email Address Mobile Phone

Address Data City of Residence Country of Residence Address in Thailand

Passport and Visa Data Passport Number Place of Issue Expiry of Passport (YYYY-MM-DD) Current Visa Number Visa Type Date of last entry to Thailand (YYYY-MM-DD)

Place of last entry to Thailand

Current visa is valid until (YYYY-MM-DD)

Notification in Case of Emergency Name Telephone Email Relationship to Card Holder

Medical Data Blood Type Allergies Previous Surgeries Permanent Sicknesses Medicine Taken (permanent/temporary) Further Notes

Comment Comment