nh

3x4
(c ng
du gip
lai)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
---------------

S YU L LCH
I- PHN BN THN

H v tn khai sinh:.....(Nam/N):...
Tn thng gi: ....
Ngy sinh: .
Dn tc: ... Tn gio:......
H khu thng tr: ...
....
S chng minh nhn dn (nu c): ....
Ch hin nay:: ..
Ngh nghip: ....
Ni lm vic (nu c): ..
in thoi lin h (nu c): ..
on th tham gia (ng vin, on vin):
ang l sinh vin trng (nu ang hc): ..
Qu trnh hc tp v lm vic(ghi t sau khi tt nghip THPT hoc tng ng):
Thng, nm

Hc hoc lm vic g

...............

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...............

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...............

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...............

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...............

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...............

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...............

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1

II- PHN GIA NH

H v tn B:.. Nm sinh: .
Ngh nghip: ..
Ni : ..
H v tn M: .. Nm sinh:
Ngh nghip: ...
Ni : ..
H v tn V (hoc Chng): .. ..Nm sinh: ....
Ngh nghip: ...
Ni : ..
Ti xin cam oan nhng ni dung khai trn y l ng s tht, nu sai ti xin chu
hon ton trch nhim theo quy nh php lut.
, ngy .. thng nm ...
Ngi khai
(k v ghi r h tn)

XC NHN CA CHNH QUYN A PHNG (CP PHNG/X)

HOC C QUAN QUN L NGI D TUYN
Ti l: .... Chc v: ....
Xc nhn bn s yu l lch ca anh (ch):...
hin nay sinh sng (hoc lm vic) ti:....
......
khai trn l ng s tht.
.., ngy .... thng . nm .
(k tn v ng du)