BAO HIM XA HI VIT NAM

NGHA VIT NAM

CNG HOA XA HI CHU

c lp - T do - Hanh phuc
Mu s: 01-TBH
(Ban

hanh kem theo Q s

1333/QBHXH ngay 21/02/2008 cua
BHXH VN)

T KHAI
THAM GIA BAO HIM XA HI, BAO HIM Y T BT BUC
S

s:

A. NGI LAO NG:

Ho va tn: TRN NGUYN NGOC.

Nam x

Ngay, thang, nm sinh: 2/8/1983, Dn tc: Kinh.

tch: My.
Nguyn quan: .
Ni c tru: 0.
Chng minh th s: 0, Ni cp: 0, Ngay cp: 0.
S the bao him y t:
Ni ng ky kham cha bnh ban u: Y t c quan.
Quyn li kham cha bnh:
+ Ngi co cng :
-Loai A:
-Loai B:
+ Sng hoc lam vic khu vc I, II, III:
- Thi gian cng tac co ong bao him xa hi:
T
thang
/
nm

n
thang/
nm

1
7/2008

2
7/2008

Cp bc, chc vu,

chc danh ngh; cng
vic; ni lam vic;
(tn c quan, n v, a
ch)
3
Cng nhn vn hanh
thit b-bc 1/6
A2-N2-X nghip May 2B
Cng ty C phn Vinatex
a Nng
25 Trn Quy Cap, a
Nng

Quc

Phu cp
Tin
lng,
tin
cng
4
1,67

Ch
c
vu

TN
VK

TN
Ngh

Khu
v
c

Ghi
chu

B.THN NHN
S

Tt
1
2
3
4
5
6

Ho va tn

Ngay,
thang,
nm sinh

Quan
h

Ngh
nghip

Thu
nhp

C tru

Cam kt: Nhng ni dung k khai trn la hoan toan ung s

thc, nu sai sot ti xin hoan toan chu trach nhim trc
phap lut.
a Nng, Ngay 01
thang 8 nm 2009
Ngi khai

TRN NGUYN NGOC

C. XAC NHN CUA NGI S DUNG LAO NG.
C quan, n v, t chc: Cng ty C phn Vinatex a Nng.
Sau khi kim tra, i chiu h s gc cua ng: TRN NGUYN
NGOC.
Xac nhn cac ni dung k khai trn la hoan toan ung s thc.
a Nng, ngay 15
thang 8 nm 2009
Ngi
s dung lao ng

D. XA NHN CUA C QUAN BAO HIM XA HI:

Bao him Thanh ph a Nng sau khi kim tra, i chiu vi h s
gc cua ca nhn ng: Trn Nguyn Ngoc. Xac nhn cac ni dung k khai
la ung.
a Nng, ngay
................................................thang. nm 2008
Can b thm nh
C BHXH

GIAM