C NG HO X H I CH NGHA VI T NAM

c l p T do H nh phc
-------------------------------------B N CAM K T THNG BO NH K
V TNH HNH PHT TRI N C A CON NUI
Chng ti/Ti l :
NG

H v tn
Ngy, thng, nm
sinh
Quc tch
Ni thng tr
H chiu/Giy t
hp l thay th
S
Ni cp
Ngy, thng, nm
cp

ang lm th t c xin nh n tr em d i y lm con

nui:
H v tn :....................................................Gii tnh :............
Ngy, thng, nm sinh :...........................................................
Ni sinh : ................................................................................
Dn tc :...................................Quc tch :...............................
Vi c xin nh n con nui ny c s gip c a (1) :
...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
...............................................................................................
Nu c nhn tr em ni trn lm con nui, chng
ti/ti cam kt trong ba nm u, nh k 06 thng mt ln, gi
thng bo v tnh trng pht trin mi mt ca con nui (c km

theo nh) cho C quan con nui quc t thuc B T php v

y ban nhn dn tnh/thnh ph ....................................., sau
, mi nm tip theo gi thng bo mt ln cho n khi con
nui 18 tui. Thng bo s c gi qua bu in hoc qua
vn phng con nui.
Bn cam kt ny c lm thnh 03 bn chnh, 01 bn
lu ti S T php, 01 bn gi cho C quan con nui quc t
thuc B T php, 01 bn do ngi lm cam kt gi.
Lm ti......, ngy...........thng....nm ......
NG
(K v ghi r h tn)

B
(K v ghi r h tn)