CNG AN HUYN TRNG BOM

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
.., ngy........thng........nm.
GIY XC NHN NHN THN

Cng an huyn Trng Bom, thuc tnh: ng Nai tnh xc nhn:

ng/b

:............................................................ Gii tnh :...............................

Sinh ngy

:..................................., ti ......................................................................

Ni ng k thng tr:...........................................................................................
.................................................................................................................................
Ni hin ti:..........................................................................................................
S CMND :..... cp ngy ......// ti.
L ngi khng ang trong thi gian b truy cu trch nhim hnh s, khng ang
trong thi gian chp hnh bn n hnh s hoc quyt nh p dng bin php x l hnh
chnh a vo c s gio dc, c s cha bnh, gio dc ti x, phng, th trn.
TRNG CNG AN

(K, ghi r h tn v ng du)