E-mail address Telephone number Fax number Mobile phone number 2. Principal place of practice Firm Name Position in the firm Address City State Postcode Country E-mail address Telephone number Fax

_______ Country _______ Expiry date _______ Home Address _______ City State Postcode Country E-mail address Telephone number Fax number Mobile phone number 2. Principal place of practice Firm Name Position

number, mobile phone number or e-mail of which companies shall update a name list and contact information regularly. Additionally, companies should specify additional communication channels, such as SMS

the responsible officer and a person having authority to decide and preparing the list of names and telephone numbers of related persons and notifying the responsible person (For example: call out tree

preparation and submission of daily status report in text file via OFAR Version 1.7 Intermediaries Supervision Policy Department Telephone: 0-2263-6257 Facsimile: 0-2263-6487

ผู้ใช้งาน การควบคุมอุปกรณ์คอมพิวเตอร์และสื่อสารเคลื่อนที่และการปฏิบัติงานจากภายนอกองค์กร (mobile computing and teleworking) เป็นต้น) ( การจัดให้มีการตรวจสอบและประเมินความเสี่ยงด้านสารสนเทศ อย่างน้อยปีละ

: ............................................(authorized person) for and on behalf of ................................... Contact person: .................................................... Phone: ......................... E-mail

: Type of Business: __________________________ Head Office: __________________________________________________________________ Registration Number: Home Page (if any): ________________________ Telephone

comply with the requirements accordingly. Sincerely -signature- (Mr. Vorapol Socatiyanurak) Secretary-General Intermediaries Supervision and Development Department Telephone: 0-2263-6255 Fax: 0-2263-6446

: ......................... Sub-district: ................. District: ...................... Province: .................. Telephone: ................................................... Facsimile