Mu 12

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc
.............................. 1, ngy....... thng..... nm 20.....
N NGH
Cp li giy php hot ng do b mt hoc h (hng) hoc b thu hi
Knh gi: S Y t tnh ng Thp.
Tn c s:...............................................................................................................
a im: 2...........................................................................................
in thoi:.............................................. Email (nu c): .....................................
Giy php hot ng s: ................................., Ngy cp:..................................
ngh cp li giy php hot ng v l do:
1. B mt

2. B h (hoc hng)

3. B thu hi do cp khng ng thm quyn

Knh ngh S Y t xem xt v cp li giy php hot ng./.

GIM C/CH C S
(K tn v ng du)

1. a danh.
2. a ch c th ca c s