CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
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S YU L LCH
PHN I: LCH S BN THN
1. H v tn:...............................................................2. Nam, N:............................
3. Ngy thng nm sinh:..........................Ni sinh:...................................................
4. Thng tr s nh:. ng................
Phng, x:................Qun, huyn:..........
5. Dn tc:..................Tn gio:...........
6. Trnh vn ha:...
Ngoi ng:.............................................................................................................
7. Ngy tham gia t chc (nng hi, hi ph n, cng on)....................................
ti:..........................................................................................................................
8. Ngy vo on thanh nin cng sn H Ch Minh:.............ti.............................
9. Ngy vo ng cng sn Vit Nam:.....................................ti.............................
10. Qu trnh bn thn (tm tt t lc 12 tui n nay, lm g? u?)
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PHN II: QUAN H GIA NH
11. H tn cha:...........................Sinh nm: ..
Ngh nghip (chc v v cp bc) trc v sau 30-4-1975
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Ch hin nay:....................................................................................................
12. H tn m:............Sinh nm:.......
Ngh nghip (chc v v cp bc) trc v sau 30-4-1975
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Ch hin nay:....................................................................................................
13. H tn v (hoc chng)Sinh nm:.......
Ngh nghip (chc v v cp bc) trc v sau 30-4-1975
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Ch hin nay:....................................................................................................
14. H tn cc con: tui, lm g? u?
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15. H tn anh, ch, em rut: tui, lm g? u?
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Ngy......thng.....nm...........
Ngi lm n
(k tn)
H tn..................................
NHN XT V CHNG NHN CA CHNH QUYN A PHNG
Ni dung chng nhn cn ghi bn l lch ny ng hay sai. Nu sai th ghi r sai ch no, c th nhn xt thm v t
cch ngh nghip v hon cnh ngi xin vic lm.

Ngy......thng.....nm...........
UBND Phng, X...............

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