CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

nh mu
4x6cm
(c ng du
gip lai ca
ca c quan
xc nhn l
lch)

S YU L LCH
T THUT

H v tn:........................................................................................Nam, n: ........................
Sinh ngy......... thng......... nm..............................................................................................
Ni ng k h khu thng tr hin nay: .........................................................................
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Chng minh th nhn dn s:............................................. Ni cp: .....................................
Ngy................. thng......... nm..............................................................................................
S in thoi lin h: Nh ring ................................ Di ng..............................................
Khi cn bo tin cho ai? u?: ..............................................................................................
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S hiu:..................................
K hiu:..................................

H v tn: ................................................................ B danh:.................................................

Tn thng gi: ......................................................................................................................
Sinh ngy......... thng......... nm...................Ti:....................................................................
Nguyn qun: ..........................................................................................................................
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Ni ng k thng tr hin nay: ..........................................................................................
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Dn tc: ........................................................Tn gio:...........................................................
Thnh phn gia nh sau ci cch rung t (hoc ci to cng thng nghip) .................
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Thnh phn bn thn hin nay: ..............................................................................................
Trnh vn ho: ............................................ Ngoi ng:....................................................
Trnh chuyn mn: .............................................Loi hnh o to:..................................
Chuyn ngnh o to: ...........................................................................................................
Kt np ng cng sn Vit Nam ngy........... thng............nm ........................................
Ni kt np: ............................................................................................................................
Ngy vo on TNCSHCM ngy............ thng...........nm...................................................
Ni kt np: ............................................................................................................................
Tnh hnh sc kho: ..................................... Cao...........................Cn nng:............. kg.......
Ngh nghip hoc trnh chuyn mn: ...............................................................................
Cp bc: ............................................ Lng chnh hin nay: ................................................
Ngy nhp ng: .................................Ngy xut ng: ............................................................
L do: ......................................................................................................................................

HON CNH GIA NH

H v tn b: ....................................................... Tui:......... Ngh nghip ..........................
Trc cch mng Thng 8 lm g? u? ............................................................................
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Trong khng chin chng thc dn Php lm g? u? .....................................................
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T nm 1955 n nay lm g? u? (Ghi r tn c quan, x nghip hin nay ang lm)
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H v tn m: ...................................................... Tui:......... Ngh nghip ..........................

Trc cch mng Thng 8 lm g? u? ............................................................................
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Trong khng chin chng thc dn Php lm g? u? .....................................................
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T nm 1955 n nay lm g? u? (Ghi r tn c quan, x nghip hin nay ang lm)
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H V TN ANH CH EM RUT

(Ghi r tn, tui, ch , ngh nghip v trnh chnh tr ca tng ngi)

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H v tn v hoc chng: ........................................... Tui: ..................................................

Ngh nghip: ...........................................................................................................................
Ni lm vic: ..........................................................................................................................
Ch hin nay: .......................................................................................................................
H v tn cc con:
1) ...........................................................Tui:............. Ngh nghip:.....................................
2) ...........................................................Tui:............. Ngh nghip:.....................................
3) ...........................................................Tui:............. Ngh nghip:.....................................
4) ...........................................................Tui:............. Ngh nghip:.....................................
5) ...........................................................Tui:............. Ngh nghip:.....................................
QU TRNH HOT NG CA BN THN
T thng nm
n thng nm

Lm cng tc g?

u?

Gi chc v g?

KHEN THNG V K LUT

Khen thng: ..........................................................................................................................
K lut: ...................................................................................................................................
LI CAM OAN
Ti xin cam oan nhng li khai trn l ng s thc v chu trch nhim v
nhng li khai . Nu sau ny c quan c thm quyn pht hin vn g khng
ng. Ti xin chp hnh bin php x l theo quy nh./.
Xc nhn ca Th trng C quan,
X nghip, Ch tch UBND X, Phng
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...............,ngythngnm
Ngi khai k tn