I, (Title)…………(Name)……………………………………………………….. of…………………………
Nationality, having applied for a permit to continue my stay in the Kingdom for reason
of ………………………………………………………………………………………………………………..
do hereby acknowledge the terms and conditions applicable to this permit. I confirm that if I am
permitted to stay, I will perform only those duties or stay according to the abovementioned reason
as approved. If at any time the conditions or status of my stay changes from the premises upon
which this permit was granted, I acknowledge that my failure to do so will be considered sufficient
cause for my permit to stay to be immediately terminated, as a consequence of which I and my
dependents associated with this permit may be subjected to legal action in accordance with the law
of Thailand.