MÉu M.02/LS
tæng l·nh sù qu¸nCHXHCN ViÖt nam
t¹i San Francisco – Hoa Kú
San Francisco, CA 94109Tel: (415) 922-1707Fax: (415) 922-1848www.vietnamconsulate-sf.
org
céng hoµ x· héi chñ nghÜa ViÖt na
§éc lËp - Tù do - H¹nh phóc
========================
Tê khai®Ò nghÞ CÊp hé chiÕu /giÊy th«ng hµnh
(Dïng cho c«ng d©n ViÖt Nam ë n
−
íc ngoµi)
-Nép 3 ¶nh, cì 4x6cm, ¶nh chôpm¾t nh×n th¼ng,®Çu ®Ó trÇn, kh«ng®eo kÝnh mÇu-
¶
nh chôp c¸ch ®©ykh«ng qu¸ 1 n¨m.-D¸n mét ¶nh vµokhung nµy
1. Hä vµ tªn (
ch÷ in hoa
).....................................................................2. Nam hay n÷……..…….3. Sinh ngµy............ th¸ng..............n¨m ...............t¹i....................................................................4. GiÊy chøng minh nh©n d©n (nÕu cã) sè: ................................................................... ...............Ngµy cÊp........................................C¬ quan cÊp.........................................................................5. §Þa chØ th
−
êng tró ë ViÖt Nam tr
−
íc khi xuÊt c¶nh (
nÕu cã
): Sè nhµ (xãm th«n)..................®
−
êng phè.......................................ph
−
êng (x·, thÞ trÊn) ................................................ ..............quËn (huyÖn, thÞ x·)..................................................tØnh (thµnh phè)......................... ...................6. NghÒ nghiÖp, tªn c¬ quan, tæ chøc vµ ®Þa chØ ®· lµm viÖc tr
−
íc khi xuÊt c¶nh (
nÕu cã
):........................................................................................................................................................ ............7. XuÊt c¶nh ViÖt Nam ngµy...........th¸ng........ n¨m......... qua cöa khÈu.........................................®i n
−
íc ................................... ........................................................................................................H×nh thøc xuÊt c¶nh: Hîp ph¸p
bÊt hîp ph¸p
. §Õn n
−
íc së t¹i ngµy.................................8. §Þa chØ cø tró hiÖn nay:.............................................................................................................................................................................................§iÖn tho¹i............................................................9. Quèc tÞch n
−
íc ngoµi (
nÕu cã
): .....................................................................................................10. NghÒ nghiÖp, tªn c¬ quan/ tæ chøc vµ ®Þa chØ hiÖn ®ang lµm viÖc ...........................................................................................................................§iÖn tho¹i ...........................................................11. C¸c giÊy tê n
−
íc së t¹i cÊp (lo¹i, sè, ngµy cÊp)................................................................................................................................................................................................................................... .......................................................................................................................................................... ....12. GiÊy tê xuÊt c¶nh do chÝnh quyÒn ViÖt Nam cÊp tr
−
íc ®©y (
nÕu cã
):Hé chiÕu ngo¹i giao - c«ng vô - phæ th«ng sè......................ngµy cÊp ........../........./..................... ...C¬ quan cÊp............................................................cã gi¸ trÞ ®Õn .....................................................13. C¸c giÊy tê nép kÌm theo (
nÕu cã
):- Hé chiÕu hoÆc GiÊy th«ng hµnh ViÖt Nam ®
−
îc cÊp tr
−
íc ®©y (
nÕu cã
):Lo¹i...........................sè..........................ngµy cÊp..................c¬ quan cÊp........................................- GiÊy tê chøng nhËn nh©n th©n cã ¶nh ®ãng dÊu gi¸p lai (nÕu cã):Lo¹i................................sè..........................ngµy cÊp..................c¬ quan cÊp...................................
-GiÊy tê chøng minh cã quèc tÞch ViÖt Nam (
nÕu cã
ghi râ lo¹i giÊy tê, ngµy cÊp, c¬ quan cÊp):
Lo¹i ............................sè..........................ngµy cÊp..................c¬ quan cÊp......................................14. Nay ®Ò nghÞ : cÊp hé chiÕu
(lo¹i........................); CÊp GiÊy th«ng hµnh...............................Lý do.................................................................................................................................................
1700 California St., Suite
580
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