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c lp - T do - Hnh phc
S YU L LCH
PHN I: LCH S BN THN
01. H v tn: .............................................................................
02. Ngy, thng, nm sinh:. ...Gii tnh:......................
nh 3x4
03. Ni sinh:................................................................................
04. H khu thng tr:..............................................................
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PHN II: QUAN H GIA NH
17. H v tn cha:..........................................................Nm sinh: ......................
Ngh nghip trc v sau 30/4/1975:
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H khu thng tr: ........................................................................................
18. H v tn m: ..........................................................Nm sinh: ......................
Ngh nghip trc v sau 30/4/1975:
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H khu thng tr: ........................................................................................
20. H v tn anh, ch, em rut: (Nm sinh, ngh nghip, n v cng tc, h
khu thng tr)
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Ti cam oan bn khai s yu l lch trn l ng s tht, nu c iu g
khng ng ti xin chu trch nhim trc php lut v li khai ca mnh./.
, ngy thng nm
Ngi khai
(k tn)