Fillable APPLICATION FOR SMART VISA EXTENSION

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APPLICATION FOR SMART VISA EXTENSION

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BOI SV-EX-02-01 18/12/2020 Page 1 of 7
APPLICATION
FOR SMART VISA EXTENSION
Part A : Personal Information
1.Full English name as in passport
First name
Middle name
Last name
2.Current Nationality / Nationality at birth, if
different
3.Date of birth (dd-mm-yyyy)
4.Place of birth (city, province/state, country)
5.Sex
Male Female
6.Marital status
Single Married Divorced Other (Please specify)
7.Passport number
8.Date of issue (dd-mm-yyyy)
9.Valid until (dd-mm-yyyy)
Current address in Thailand (if any)
10.Home/Mobile phone
11.E-mail address
12.Spouse
Name
Nationality
Occupation
Wish to apply for
Smart Visa*
☐
13.Children
☐
☐
☐
☐
14. Current Visa
Smart “T” Smart “I” Smart “E” Smart “S” Smart “O”
15.Valid until (dd-mm-yyyy)
16. Job position
17.Job description
18.Name of contact person in Thailand
Relationship with the applicant
E-mail address
Mobile phone number
*Spouse and children wishing to apply for Smart Visa must submit their own application separately.
Part B : Targeted industries
1. For Smart Visa holder T, I and E, please choose the targeted industries most relevant to your company’s activities
☐ Next-Generation Automotive
☐ Automation and Robotics
☐ Smart Electronics
☐ Aviation and Logistics
☐ Affluent, Medical and Wellness Tourism
☐ Biofuels and Biochemicals
☐ Agriculture and Biotechnology
☐ Digital
☐ Food for the Future
☐ Medical Hub
☐ Human Resource Development in Science and Technology
☐ Environmental Management and Renewable Energy
☐ Alternative Dispute Resolution
M
M
M
M
Chen Wei
Chou
Canada
03-11-1990
Taipei, Taiwan
✔
HP917756
17-01-2017
17-01-2027
882/117 TC Green Condo, Rama 9 Road, Huaykwang,
Bangkok, Thailand 10310
0659844655
jerry.cw.chou@gmail.com
✔
08-07-2022
As a founder, my role spans from setting up supplier partnerships, defining product requirements to build webapp, optimizing marketing strategies, to recruiting and legal and finance. I lead a
team of 6 and ensures the team is aligned on key growth metrics and prioritizing their tasks in a fast-paced environment. Lastly, I serve as the advocate for Telemedicine and builds relations with
the regulators and the ecosystem to advance adoption
Fiancee
jutharat.c@hotmail.com
+66989424655
08-07-2022
CEO
Jutharat Cheevakulprasit
BOI SV-EX-02-01 18/12/2020 Page 2 of 7
2. For Smart Visa holder S, please choose the startup sectors/ targeted industries /startup stage most relevant to your activities
Startup Sectors
Targeted Industries
Startup Stage
☐ HealthTech
☐ Next-Generation Automotive
☐ Idea
☐ TravelTech
☐ Smart Electronics
☐ Prototype
☐ FinTech
☐ Affluent, Medical and Wellness Tourism
☐ Launched
☐ Business/ ServicesTech
☐ Agriculture and Biotechnology
☐ Scale up
☐ IndustryTech
☐ Food for the Future
☐ PropertyTech/ UrbanTech
☐ Automation and Robotics
☐ GovTech/ EdTech
☐ Aviation and Logistics
☐ LifestyleTech
☐ Biofuels and Biochemicals
☐ AgriTech/ FoodTech
☐ Digital
☐ Other (please specify)
☐ Medical Hub
☐ Human Resource Development in Science and Technology
☐ Environmental Management and Renewable Energy
Please select the type of visa you wish to apply (only one answer is possible)
☐ Smart T
Please complete Part C
☐ Smart T (Government sponsor / higher
education institutions / specialized
institutions / Alternative Dispute
Resolution)
Please complete Part D
☐ Smart I
Please complete Part C and F
(Form A, in case the applicant has
invested more than one company)
☐ Smart E
Please complete Part C
☐ Smart S ( 2-year visa)
Please complete Part C
☐ Smart S (6-month visa)
Please complete Part E
☐ Smart O
Please complete Part G
Part C : Company and employment information
1. Company name
2. Company registration number
3. Address
4. Office number
5. Company website or e-mail address
6. Business or products or services description
7. Major products or services
Sale revenue (Approximate in Baht)
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Endose Co., Ltd.
0105563054712
7 Summer Point Building 2 fl., Soi Sukhumvit 69, Phra
Khanong Nuea, Wattana, Bangkok 10110
30
https://www.sayhibro.com/
A telemedicine platform that provides consultation and medicine delivery to men with sexual
health and hair loss problems. We want to make our fellow man go through the treatment
experience in the most comfortable way possible. The technology-focused approach allows us to
digitalize entire user journey including: consultation, medicine delivery and follow ups.
Delivering products to patients from hospitals/pharmacies
Currently 70,000-100,000THB/month
Premium services for patients (medication review)
Est ~1.3M THB per year at 30% margins and 3% market penetration
BOI SV-EX-02-01 18/12/2020 Page 3 of 7
8. Manufacturing/Service Process
Please provide a process diagram that explains the manufacturing/service process (additional documents can be attached).
Process Diagram
Explanation
9. Acquisition of core technology
Import
Procurement/Sourcing in Thailand
Developed by own company
10. Objective of technology employment
To apply to the production process or service provision To significantly increase the value of products or services
Please explain
11. Contract term
Years Months Period (dd-mm-yyyy to dd-mm-yyyy) Other (Please specify)
12. Average income per month* (Baht)
Salary (Baht per month)
Other items of income (Please specify)
13. The applicant’s involvement in company
Employee Director % of Shares Other (Please specify)
Part D : Data of the employer or sponsor in Thailand
1. Organization name
2. Address
3. Phone number
4. Type of Organization Government agency Educational institution Arbitration center/institute
5. A reference person’s name
A reference person’s position
E-mail address
Mobile phone number
Part E : Business progress
1. Company registration progress
1. Having reserved the company name.*
2. Having registered the memorandum of association*
3. Having hold a statutory meeting
4. Having registered a company
* Prerequisite for visa extension
2. Name of your stakeholders whom you have already contacted.
Name
Company/Organization
Position
Contact detail
(e.g., E-mail or phone number)
p
p
p
p
p
1. Patients register their information on Endose's platform and input their medication history
2. The platform will verify the medical records with our doctors to give consult and approve treatment
3. The platform will inform the application is successful and will work with clinic/pharmacy partners to
deliver the medications to patients
4. The company's pharmacist will provide consultation and review medicines before sending to
patients
5. The company's pharmacist will provide additional services such as medication review, medication
reconciliation and home-based care
Patient registration will be compliant to the applicable security laws (PDPA etc)
The platform will have controlled process to verify record with the healhcare providers
The company has three medical advisors to make sure medical and procedural compliance
We intend to expand more premium services that are a gap in the current sytems
✔
✔
We intend to use data analytics, including big data and AI, to identify patient behavior and providea better
experience throughout their patient journey. The data will help us pinpoint the right target audience, provide insights
on supply chain management, and improve the interoperability of medical records.
✔
Permanent
NA until raising money
NA until raising money
✔
✔
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49%
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Dr. Akanae Wongsawatงษ์สวัสดิ์
Medpark Hospital
Urologist & Medical Advisor
akan_wong@hotmail.com
Dr. Phatcharawat Chirasuthat
Ramathibodi Hospital
Dermatologist & Medical Advisor
bunji-taru@hotmail.com
Chuwit Waisiriroj
Bangkok Drugstore
Deputy Managing Director
chuwit.w@gmail.com
BOI SV-EX-02-01 18/12/2020 Page 4 of 7
Part F : Private investment
1. Please select all types of your investment.
Direct investment in technology-based business in Thailand.
Investment through a venture capital company which has invested technology-based business in Thailand.
Direct investment in a startup or an incubation or accelerator business in Thailand.
2. List of companies in which the applicant has invested.
Company name
Value of shares (Baht)
Amount of convertible debt
(Baht)
The same company as the last
Smart Visa application
Yes No
Yes No
3. Total value of shares owned by the applicant (Baht)
Note : In case the applicant has not invested in the same company as the last Smart Visa application, please fill
in FORM A attached.
Part G : Smart O
1. Please specify the name of Smart Visa “ T”, “E”, “I” or “S” holder or applicant whom you will accompany
First name
Middle name
Last name
2. Type of his/her Smart Visa
Smart “T” Smart “I” Smart “E” Smart “S”
3. Relationship with the main Smart Visa holder/applicant.
spouse child
Details of Smart “O” applicant’s work or study in Thailand (Please fill in this part only in the case where
applicant is working or studying in Thailand.)
4. Name of company or education institution in Thailand
5. Job position or current education level
6. Work address or education institution address
7. Phone number
8. E-mail address
9. A reference person’s name
A reference person’s job title
E-mail address
Mobile phone number
I hereby certify that the information and the evidence provided is true and complete in all respects. If there are
any false statements which are considered perjury, I agree to be subjected to any applicable legal prosecution.
BOI SV-EX-02-01 18/12/2020 Page 5 of 7
FORM A
The data provided herewith is crucial in helping us identify whether your companies are qualified as
companies using technology in manufacturing or delivering services and being in the targeted industries.
Company Profile
1. Company name in Thailand
2. Registration date (dd-mm-yyyy)
3. Registered number
4. Address
5. Office number
6. Company website or e-mail address
7. Business / products or services description
8. Major products or services
Sale revenue (Approximate in Baht)
Annual sale revenue in total
9. Amount of share (Baht)
10. Value per share (Baht)
11. Shares owned by applicant (Baht)
12. Please choose the targeted industries most relevant to your company’s activities
☐ Next-Generation Automotive
☐ Automation and Robotics
☐ Smart Electronics
☐ Aviation and Logistics
☐ Affluent, Medical and Wellness Tourism
☐ Biofuels and Biochemicals
☐ Agriculture and Biotechnology
☐ Digital
☐ Food for the Future
☐ Medical Hub
☐ Human Resource Development in Science and Technology
☐ Environmental Management and Renewable Energy
13. Manufacturing/Service Process
Please provide a process diagram that explains the manufacturing/service process
Process Diagram
Explanation
Endose Co., Ltd.
27-03-2020
0105563054712
7 Summer Point Building 2 fl., Soi Sukhumvit 69, Phra
Khanong Nuea, Wattana, Bangkok 10110
30
A telemedicine platform that provides consultation and medicine delivery to men with sexual
health and hair loss problems. We want to make our fellow man go through the treatment
experience in the most comfortable way possible. The technology-focused approach allows us to
digitalize entire user journey including: consultation, medicine delivery and follow ups.
Delivering products to patients from hospitals/pharmacies
70,000-100,000 THB per month
Premium service to patients (medical review)
Est 1.3M THB first year at 20% margins and 3% market penetration
Est 1.3M THB first year at 20% margins and 3% market penetration
30,000
100
14,700
✔
✔
✔
1. Patients register their information on Endose's
platform and input their medication history
2. The platform will verify the medical records with our
doctors to give consult and approve treatment
3. The platform will inform the application is successful
and will work with clinic/pharmacy partners to deliver the
medications to patients
4. The company's pharmacist will provide consultation
and review medicines before sending to patients
5. The company's pharmacist will provide additional
services such as medication review, medication
reconciliation and home-based care
Patient registration will comply to the applicable security laws (PDPA etc)
The platform will have strict process to verify records with healthcare partners
The company will hire a pharmacist to make sure process compliance
We intend to provide premium services that are a gap in the current systems
https://www.sayhibro.com/
30
BOI SV-EX-02-01 18/12/2020 Page 6 of 7
14. Please select the core technology used in the production process or services provision
1.
3D Printing Technology Rapid /Prototyping/
Additive Manufacturing
30.
Electric Vehicle Technology
2.
5G Wireless Communications Technology
31.
Embedded Technology
3.
Adsorption Technology
32.
Energy Storage Technology
4.
Advanced Bioprocessing Technology
33.
Functional Materials Technology
5.
Advanced Catalyst Technology
34.
Gene and Molecular Technology
6.
Advanced Food Processing Technology
35.
Genetic Engineering Technology
7.
Advanced Materials Characterization Technology
36.
Human Machine Interaction Technology
8.
Advanced Material Processes
37.
Internet of Things (IOT) Technology
9.
Advanced Membrane Technology
38.
MSTQ Technology (Metrology, Standardization, Testing
and Quality Assurance)
10.
Advanced Sensor Technology
39.
Nano Encapsulation Technology
11.
Aerospace Technology
40.
Nanofiber Technology
12.
Artificial Intelligence Technology
41.
Nanomaterial Synthesis Technology
13.
Automation Technology
42.
Nanostructure Fabrication Technology
14.
Autonomous Vehicle Technology
43.
Natural Language Processing Technology
15.
Big Data Technology
44.
Omics technology
16.
Bio-Analytical Technology
45.
Photonics & Optical Technology
17.
Bio-based Material Technology
46.
Pre-Clinical & Clinical testing Technology
18.
Biodegradable Materials Technology
47.
Printed Electronics and Organic Electronics Technology
19.
Bioinformatics
48.
Robotics Technology
20.
Biomedical/Biocompatible Materials Technology
49.
Smart grid
21.
Bio Medical Engineering Technology
50.
Software Testing Technology
22.
Block chain Technology
51.
Solar Cell (photovoltaic Technology)
23.
Cell Culture and Tissue Engineering Technology
52.
Surface Coating/ Surface Engineering
24.
Composite Materials Technology
53.
Thermal Solar Technology
25.
Cyber/IT Security Technology
54.
Virtual/Augmented Reality (VR/AR) Technology
26.
Data Analytics Technology
55.
Waste treatment & Utilization Technology
27.
Digital Engineering Technology
56.
Wearable Technology
28.
Drug Delivery Systems
57.
Wind Energy Technology
29.
Edge Computing/ Fog Computing
58.
Other (please specify)
15. Acquisition of core technology
Import
Procurement/Sourcing in Thailand
Developed by own company
Please explain
16. Objective in using technology employment
To apply to the production process or services provision To significantly increase the value of products or services
Please explain
✔
✔
✔
✔
✔
✔
We worked with two local developer agencies to build the backend systems (React and Next.JS) for us, as well as 1
UX/UI agency to build the frontend design. Since the product launch, we have hire both employees and performance
marketing agency to do marketing acquisition for us. Later on, we will focus on data analytics and AI to particularly
predict patient behaviors to help build a better product and manage the supply chains. We will also custom build
dashboards for B2B partners to better manage their patients in addition to their healthcare IT systems
We intend to use data analytics, including big data and AI, to identify patient behavior and provide
a better experience through their patient journey. The data will help us pinpoint the right target
audience, provide insights on supply chain management, and improve the interoperability of
medical records between providers.
SUPPORTING DOCUMENTS SUBMITTED
Applying Type of Smart Visa
T
I
E
S
(6M)
S
(2Y)
O
1.
Completed application form for smart visa extension
2.
Copy of valid passport (first page and all pages with Thai visa stamps)
EVIDENCE OF EMPLOYMENT AND CORPORATE
3.
Evidence of employment contract or service contract with entity in Thailand
(and a letter signed by an authorized person) which include details of employment
e.g. position, length of employment (the remaining period of employment contract
must be at least 1 year), income or evidence of working for a government agency
∆
4.
Shareholders list in Thailand (not more than 3 months old) or/and transfer slip
5.
Company profile or annual report
6.
Evidence of payment of annual income tax
(e.g. Por Ngor Dor 1 of latest three months or Por Ngor Dor 91 of the previous year)
7.
Latest audited corporate’s annual financial statement or financial report
8.
Foreign Business License or Foreign Business Certificate
*In case of a foreign majority company in restricted business activities under the
Foreign Business Act
∆
ADDITIONAL INFORMATION
9.
Financial evidence showing a deposit of no less than 600,000 Baht or equivalent
in a bank account which has been held for at least 3 months.
*In the case of a smart S visa holder being accompanied by spouses and children,
an additional amount of fixed saving of at least 180,000 Baht per person or
equivalence is required.
∆
10.
Health insurance policy covering entire course of stay in Thailand, with coverage
for hospitalization treatment of no less than 500,000 Baht
(For Smart “S” applicants and Smart “O” accompanying Smart “S” only)
∆
11.
Proof of reservation of company's name
12.
Registered memorandum of association
13.
The most up-to-date pitch deck
14.
Business progress report (Please see items to be covered in the following page)
15.
Evidence of family relationship (i.e. marriage certificate, birth certificate)
Note: Certificate of incorporation, memorandum of association in Thailand, may
be requested on a case-by-case basis.
∆
∆
∆
∆
∆
∆
Mandatory ∆ If applicable
I confirm that I have read the guidance and there are no other documents to submit. For document are not in
English, I have provided a certified translation.
I hereby authorize One Stop Service Center for Visa and Work Permit and related govenmental institutions to share
this information provided among the agencies involved in this qualification endorsement process.
I understand that a decision may be made on my application based on these documents only.
I understand that I may be contacted or requested for additional documents or information from government offices or
its representative.
* All processes may take approximately 30 working days to process providing that you are able to provide all complete
documents at the start, so please allow considerable time to begin the process before your immigration stamp expires.
For Official Use Only
Registered Number: Received Date: Due date:
Submission Officer’s Name Signature
Required documents for Smart visa extension
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click to sign
signature
click to edit
Items to be in business progress report (for Smart “S” only)
Information can be provided in any forms, e.g., A4 report, PowerPoint presentation, video
1. Product development progress - (e.g., prototype designing or development of your
product or service, demo, minimal viable product, mockup product)
2. Customer testimonial
3. Company structural progress - Provide evidence of your company’s legal procedures
(e.g., Certificate of incorporation, required licenses, permits)
4. Technical development progress - (e.g., platform)
5. Agencies you developed a partnership with - Provide evidence showing a partnership
between your business and agency.
6. Human resources development progress - Describe courses or training you provided,
new employees hired, or any activities related.
7. Updated business timeline - Including what milestones you have achieved, your
present activity, and your future business plan
8. Updated financial plan (if any)
9. Updated marketing plan (if any)
10. Difficulties – Please describe problems encountered in doing business.
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APPLICATION FOR SMART VISA EXTENSION

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Completed 6 May 2022

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