KINGDOM OF THAILAND
BANGKOK METROPOLIS
EMBASSY OF THE UNITED STATES OF AMERICA
I, ________________________________________________, being duly sworn, do hereby depose and state:
(Full name as it appears on presented ID)
1. I was born on ________________________ at ________________________________________________
(DD/MMM/YYYY)
(City/State/Province)
(Country of Birth)
and am the bearer of ____________________________ No. _______________________________________
(ID Type)
(ID Number)
issued on _______________ by ________________________________ which expires__________________
(DD/MMM/YYYY)
(Issuing Agency/Government)
(DD/MMM/YYYY)
2. I am presently employed by _______________________________________________________________
(Name of Employer/Retired/Unemployed)
and reside at:_____________________________________________________________________________
(Local Address in Full)
________________________________________________________________________________________
3. The purpose of this affidavit is to affirm:_____________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
4. The U.S. Embassy does not guarantee the contents of my own sworn statement. Under penalty of perjury, I
assume full and complete responsibility for the veracity of the claims herein.
______________________________
(DO NOT SIGN until so instructed)
Subscribed and sworn before me on this date:______________________________
(Seal)
(To be stamped by U.S. Embassy)
______________________________
Commission: Indefinite