Official Emblem Chor.5 Form No. 577/2555 Surename Change Registration Certificate Miss ชื่อ นามสกุล Identification No. 0-0000-00000-00-0 Residing at house No. 00/00, 22 Road, Minburi Sub-district, Minburi Dristrict, Bangkok Metropolis. Fathers name : xxx Mothers name : xxx Request to change the surname to be : xxx In case : Marriage The registrar has granted the permission according to the application No. 1977/2555, dated 17 July 2012 Therefore, the registrar hereby issued this certificate as evidence. Office of : Minburi District, Bangkok Metropolis. Given on 17 July 2012 Signature ( Miss Boonnak Petchara) Local Registrar (Official seal affixed) ( Miss Boonnak Petchara) Governing Officer, Professional Level Acting Chief of Registration Section For Minburi District Director |