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CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

N XIN XC NHN
HON CNH KH KHN
Knh gi:

UBND x, (phng):....................................

1. Ti tn l:.Sinh ngy:............................
2. Qu qun:................................................................................................
3. a ch (tm tr): ....................................................................................
.....................................................................................................................
4. Hin l sinh vin lp:.............Khoa ., Trng .............................
5. M s sinh vin:.......................................................................................
6. im trung bnh hc k...........................,..im.
Xin c xc nhn gia nh ti hin ang c hon cnh nh sau:
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
.....................................................................................................................
7. Gia nh thuc din:
Chnh sch c, Vng su c , H ngho c
Cha:.........................,.....tui, hin ti:...................................
Ngh nghip: ..............................................................................................
M:..............................,....tui, hin ti:....................................
Ngh nghip:...............................................................................................
Khc (cha m ly thn,ly d):.....................................................................
(nu mt th ghi nm v l do mt, nu bnh th ghi r bnh g, c nm
vin khng, bnh vin no? nu l thng binh th ghi r hn thng binh )
8. Gia nh canh ch em (k c ti). Ngi ln nht.tui,
Ngi nh nhttui.
S ngi cn ang i hc: Cp 1:......., Cp 2:......., Cp 3:
, i hc
9. Nh ti c ......m2 t trng (nui).. ......
10. Gia nh c
Bun bn nh (ngh nghip khc)....
11. Thu nhp bnh qun ca gia nh.ng/thng
12. Bn thn ti: Thu nhp.ng/thng (nu c)
13. L do xin xc nhn: (VD: b sung h s xin hc bng, vay vn.)

Xc nhn ca chnh
quyn a phng

,Ngythngnm 20....
Ngi lm n