MÉu TK/XC
Céng hßa x· héi chñ nghÜa ViÖt Nam
§éc lËp - Tù do - H¹nh phóc
tê khai
(Dïng cho c«ng d©n ViÖt Nam ®Ò nghÞ cÊp,söa ®æi hé chiÕu phæ th«ng ë trong níc)1. Hä vµ tªn
(ch÷ inhoa).
.................................................................................................................. 2. Nam
N÷
3. Sinh ngµy.............th¸ng............n¨m............... N¬i sinh
(tØnh,TP)..
..........................................................................4. GiÊy CMND sè Ngµy cÊp......../......../.......... N¬i cÊp
(tØnh,TP)..
...............................5. D©n téc...............................6. T«n gi¸o. ...................................7. Sè ®iÖntho¹i......................................................8. §Þa chØ thêng tró (
ghi theo sæ hé khÈu
).......................................................................................................................................................................................................................................................................................................9. §Þa chØ t¹m tró (
nÕucã)...................................................................................................................................................................................................................................................................................................................................
10. NghÒ nghiÖp ........................................11. Tªn vµ ®Þa chØ c¬ quan (
nÕucã).................................................................................................................................................................................................................................................
12. Cha: hä vµ tªn ............................................................................................sinh ngµy.........../............/...................MÑ: hä vµ tªn .............................................................................................sinhngµy.........../............/....................Vî /chång: hä vµ tªn..................................................................................sinhngµy.........../............/....................13. Hé chiÕu PT ®îc cÊp lÇn gÇn nhÊt (
nÕu cã
) sè.........................................cÊpngµy............/............/....................14. Néi dung ®Ò nghÞ
(
2
)
................................................................................................¶nhmíi chôp,mÆt nh×nth¼ng, ®Çu®Ó trÇn,ph«ng nÒntr¾ng,
¶nhmíi chôp,mÆt nh×nth¼ng,®Çu ®Ó trÇn,ph«ng nÒntr¾ngcì 3x4 cm
15. Con díi 14 tuæi ®Ò nghÞ cÊp chung hé chiÕu (
nÕu cã
):Hä vµ tªn (
ch÷ in hoa
).. ...................................................................Nam
N÷
Sinh ngµy.......th¸ng.......n¨m............ N¬i sinh
(tØnh,TP)..
....................................T«i xin chÞu tr¸ch nhiÖm tríc ph¸p luËt vÒ lêi khai trªn.
X¸c nhËncña Trëng C«ng an x·/phêng/ thÞ trÊn hoÆc
Lµmt¹i...........................ngµy......
th¸ng.....
n¨m
........
cña Thñ trëng c¬ quan, tæ chøc
®îc ñy th¸c
(3)
Ngêi ®ÒnghÞ
(
Ký, ghi râ hä tªn, chøc vô, ®ãng dÊu
)
(
Ký, ghi râhä tªn
)
PhÇn dµnh cho C«ng an tØnh, thµnh phè trùc thuéc TW
...................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................
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| Upload Date: | 07/04/2009 |
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