CNG HA - X HI - CH NGHA - VIT NAM

c lp T do Hnh phc

N XIN XC NHN TM TR
Knh gi : Cng an phng/x/th trn..................................................................................
Ti tn....................................................Ngy sinh................................................................
S CMND...................................Do Cng an...........................Cp ngy..............................
a ch thng tr..................................................................................................................
Ch hin nay.......................................................................................................................
Nay ti lm n ny knh xin Ban Cng an phng/x/thtrn............................. .xc
nhn cho ti tm tr ti a ny t ngy..................................cho n nay.
L do......................................................................................................................................
Xin cm n!
Xc nhn ca Cng an
phng/x/thtrn

Ngy............thng.............nm.
Knh n