CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu CM3 ban hnh theo

Q s 998/2001/Q-BCA(C11)
Ngy 10-10-2001

N NGH CP CHNG MINH NHN DN

Knh gi:
.

nh
3x4

H tn:..Nam/n................................
Tn gi khc:..........
Sinh ngy ......./.../; Nguyn qun:.................................................................
........................................................................
Ni KHK thng tr:..................................................
....................................................................
...................................................................................................
H tn cha:.....
H tn m:......
S h khu s:tp:t:.....
Ti xin c cp giy CMND, l do: (cp mi; CMND c, hng, thay i a ch, ht gi
tr s dng hoc mt)..........

Ti xin cam oan li khai trn l ng s tht.

Ngy . thng nm ..
XC NHN CA CNG AN..
NGI LM N
(phng/x/ th trn ni KHK thng tr )
(k, ghi r h tn)