CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
-----------------------------------nh
3x4
cm

N NGH I GIY PHP LI XE

Knh gi: S Giao thng vn ti TP. H Ch Minh

Ti l : ...............................................................Quc tch : .......................................

Sinh ngy : ............................ thng ................... nm ..........................
Nguyn qun : ........................................................................................................................
Ni ng k h khu thng tr : .................................................................................
..........................................................................................................................

Ni c tr : ..
..........................................................................................................................

n v cng tc : ..............................................................................................................
..........................................................................................................................

S CMND( hoc h chiu ).................... cp ngy ................. thng ..nm ...

Ni cp................ Hin c GPLX hng : .................S: ............................
do : ................................................................... cp ngy: ....... thng ....... nm .......
ngh cho ti c i giy php li xe c gii ng b hng ...................
L do ...........................................................................................................................................
Xin gi km theo :
- 01 giy chng nhn sc khe.
- 03 nh mu 3 x 4.
- Bn photocopy giy chng minh nhn dn, giy php li xe sp ht hn.
- H s gc li xe
Ti xin cam oan nhng iu ghi trn y l ng s tht, nu sai ti xin hon ton
chu trch nhim.
Xc nhn ca c quan ch qun
hoc chnh quyn a phng
( K tn, ng du )

, ngy.....thng....... nm ..
NGI LM N
(K v ghi r h tn)