˹ѧÊ×ÍÁͺÍÓ¹Ò¨ POWER OF ATTORNEY à¢Õ¹·Õè................................................................. (WRITTEN AT) Çѹ·Õè.................à´×͹.............¤.È....................... DATE MONTH YEAR ¢éÒ¾à¨éÒ (¹Ò / ¹Ò§ / ¹Ò§ÊÒÇ).....................................................ª×è͵ÑÇ.............................................. (MR / MRS / MISS) FAMILY NAME FIRST NAME ª×èÍÃͧ.............................................ÊÑ­ªÒµÔ...................ÍÒÂØ...........»Õ ¶×Í˹ѧÊ×Íà´Ô¹·Ò§ËÃ×ÍàÍ¡ÊÒÃãªéá·¹ MIDDLE NAME NATIONALITY AGE YEAR,HOLDER OF THE PASSPORT OR ˹ѧÊ×Íà´Ô¹·Ò§àÅ¢·Õè...............................................ŧÇѹ·Õè..................à´×͹.........................¤.È..................... TRAVELLING DOCUMENT NO. DATE MONTH YEAR ÍÍ¡ãËé·Õè..........................................................ÁÕÍÒÂض֧Çѹ·Õè..................à´×͹.........................¤.È..................... ISSUE AT VALID UNTIL DATED MONTH YEAR â´Â˹ѧÊ×Íà´Ô¹·Ò§©ºÑº¹Õé¢Íáµè§µÑé§ãËé (¹Ò / ¹Ò§ / ¹Ò§ÊÒÇ)....................................................................... HERE BY AUTHORIZE (MR / MRS / MISS) NAME AND FAMILY NAME à»ç¹¼ÙéÃѺÁͺÍÓ¹Ò¨¢Í§¢éÒ¾à¨éÒ ãËéÁÕÍÓ¹Ò¨àµçÁ㹡ÒÃ.................................................................................... AS OUR REPRESENTATIVE,WITH FULL AUTHORITY TO :………………………………….…… …………………………………………………………………………………………………...…………… ……………………………………………………………………………………………………………....... ŧª×èÍ...................................................... ¼ÙéÁͺÍÓ¹Ò¨ SIGNATURE GRANTOR OF AUTHORIZATION ŧª×èÍ...................................................... ¼ÙéÃѺÁͺÍÓ¹Ò¨ SIGNATURE AUTHORIZATION REPRESENTATIVE