CNG HO X HI CH NGHA VIT NAM

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

---------------------

S YU L LCH I. PHN BN THNH v tn khai sinh(Nam, N).Tn thng gi:Ngy sinh:...........Ni sinh.H khu thng tr:.Ch hin nay: .in thoi: .

n v cng tc v chc v:.

.S CMTND: .................................Ngy cp............................Ni cp.Dn tc:Tn gio.....on th tham gia (ng vin, on vin):

.Cc vn bng c:

1. Bng tt nghip: THPT BTTH THCN Nm TN:............ S hiu:.Ni cp bng:, k ngy .thng.nm ...2. Cc vn bng chuyn mn (ghi cp hc cao nht): THCN Cao ng i hc

Ngnh:Nm TN:Qu trnh hc tp v lm vic ca bn thn: (khai t thi gian khi 15 tui cho n ngy khai l lch, phi khai lin tc, r vic lm, thi gian, a ch c th)Thi gianHc hoc lm vic g u

T nmn nm

II. PHN GIA NH

H v tn B:......................................Nm sinh ...........Ngh nghip

a ch lin h:

H v tn M:.....................................Nm sinh ...........Ngh nghip

a ch lin h:

H v tn V/Chng:Nm sinh 19.........Ngh nghip

a ch lin h:

H v tn cc con:

Nm sinh ...........Ngh nghip

Nm sinh ...........Ngh nghip

Nm sinh ...........Ngh nghip

Ngy thng nm 20

Ngi khai

(K v ghi r h tn)

XC NHN CA C QUAN HOC CHNH QUYN A PHNG

(CP PHNG, X) QUN L NGI HC

Ti l: .Chc v:

Xc nhn bn s yu l lch ca anh (ch): ..hin ang sinh sng (hoc lm vic) ti: ..

..khai trn l ng s tht.

.,Ngythng..... nm 20

(K tn, ng du)

nh 4x6

ng du gip lai ca n v xc nhn h s ln trn 1/3 nh

Ti xin cam oan nhng li khai trn l ng s tht, nu c iu g sai tri, ti xin t thi hc v chu trch nhim trc php lut.

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