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					               1 Basic Personal Information                                        FOR OFFICE USE   AFS ID#

1   CANDIDATES LEGAL NAME


    TOSSAPORN                     -                               PECHSATHID                             DEAR
    (Ms.)(Mr.) First name               Middle name                     Last name                          Preferred name/nickname
2   ADDRESS FOR MAILING PURPOSES
                      73 Moo 1 Tumbon                                                                          84130
    Street/P.O. Box                                                                        Zip/Postal Code
                             Bang-ngon / Suratthani                                                    Thailand
    City & State/Province                                                                  Country
    Telephone -                        Mobile Phone 66-88-168-4722          Email address iamdkz@live.com
    Fax -                                                       Birthdate: day 25 month (spell word) October             year 1996
3    FOR VISA PURPOSES

    City of Birth Bangkok                                                  Country of Birth Thailand
                             Thailand                                                                         Thailand
    Country of Citizenship                                                 Country of Legal Residence
                                      Z219211
    Passport Number (if known)                                             Passport Issue Date 27 SEP 2012
    Place/Office of Passport Issue BANGKOK                                 Passport Expiration Date 26 SEP 2017
    Have you ever traveled to the United States on a F-1 or J-1 Visa?             Yes  No (If yes, please indicate wich type of visa and
    and name of the sponsoring institution.
4    INFORMATION ABOUT THE PEOPLE WITH WHOM I LIVE
    I live with:  Father  Mother  Stepfather  Stepmother                  Guardian Other than Parent
    Who is your custodial parent? Please circle. (If more than one, circle both).
    For Adult Programs - Additional options:  Spouse  Independent  Other
5   INFORMATION ABOUT PARENT (S)/GUARDIAN(S) WITH WHOM I LIVE
    Parent/Guardian  Male  Female
    Mrs.Siriporn                        Buakeaw                            6677-319690
    Legal name: First Name              Last Name                          Business and/or Mobile Phone
    27 Jun. 1961       Thailand                   teacher                special expertise                -
    Date of Birth  Country of Birth                  Occupation            Employer                           Email
    Parent/Guardian  Male  Female
    Mr.Udom                             Buakeaw
    Legal name: First Name              Last Name                          Business and/or Mobile Phone
    2 Dec. 1954        Thailand                   electrian              the head of electrian            -
    Date of Birth Country of Birth Occupation     Employer                                                    Email
6   CONTACT DETAILS OF ANY NATURAL PARENT WITH WHOM I DO NOT LIVE
     Mr.Kitti                           Pechsathid                         -
    Legal name: First Name              Last Name                          Business and/or Mobile Phone
    16 Aug 1963        Thailand                    Merchant               Private business                kpechsathid@hotmail.com
    Date of Birth      Country of Birth              Occupation            Employer                           Email
    89/93 MOO. 6 Tumbon kokkham Samutsakorn
    Address
7   EMERGENCY CONTAC T
    If your Parent/Guardian cannot be reached, please indicate someone else in your community whom we can contact:
    Mr.Kitti          Pechsathid                       father             66876683367
    First Name   Last Name        Relationship                             Telephone Numbers (home, work, mobile)
8   NAMES AND BIRTHDATES OF BROTHERS AND SISTERS


    Miss Pechsarat Pechsathid 17/07/1999 Mrs.Chaiyapoj pechsathid 5/12/1993

9   AFS CONNECTIONS

    Has your family: (If yes, please describe who, the relationship, where and when.)
    Hosted on AFS?  Yes  No
    Participated on an AFS program?  Yes  No
    Any close friends or relatives living abroad?  Yes  No
    Have you participated in any other exchange program, traveled abroad or lived in another country? Please provide details.


                                                                                                                               Updated Aug 2008

				
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