Mu TK/XC

Cng ha x hi ch ngha Vit Nam

c lp - T do - Hnh phc

t khai
(Dng cho cng dn Vit Nam ngh cp,
sa i h chiu ph thng trong nc)

nh
mi chp,
mt nhn
thng, u
trn,
phng nn
trng,
c 4x6cm

1. H v tn (ch in
hoa)................................................................................................................... 2. Nam
N
3. Sinh ngy.............thng............nm............... Ni sinh (tnh,
TP)............................................................................
4. Giy CMND s

Ngy cp......../......../.......... Ni cp (tnh,

TP).................................
5. Dn tc...............................6. Tn gio. ...................................7. S in
thoi......................................................
8. a ch thng tr (ghi theo s h
khu). ................................................................................................................
...............................................................................................................................................
.......................................
9. a ch tm tr (nu
c)..........................................................................................................................................
..
...............................................................................................................................................
........................................
10. Ngh nghip ........................................11. Tn v a ch c quan (nu
c)...........................................................
...............................................................................................................................................
.......................................
12.

Cha:

tn ............................................................................................sinh

ngy .........../............/...................
M: h v tn .............................................................................................sinh
ngy.........../............/....................
V /chng: h v tn..................................................................................sinh
nh
mi chp,
13. H chiu PT c cp ln gn nht (nu c) s.........................................cp
mt nhn
thng,
ngy............/............/....................
u trn,
phng nn
14. Ni dung ngh(2) ................................................................................................
trng
c 3x4 cm

ngy.........../............/....................

15. Con di 14 tui ngh cp chung h chiu (nu c):

H v tn (ch in hoa).. ...................................................................Nam N
Sinh ngy.......thng.......nm............ Ni sinh (tnh,
TP)......................................
Ti xin chu trch nhim trc php lut v li khai trn.
Xc nhn
ca Trng Cng an x/phng/ th trn hoc
ti...........................ngy...... thng..... nm........
ca Th trng c quan, t chc c y thc(3)
ngh
(K, ghi r h tn, chc v, ng du )
h tn)

Lm
Ngi
(K, ghi r

Phn dnh cho C QUAN QUN L XUT NHP CNH

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

___________________________________________________________________________
Ch thch:
(1) Np 04 nh, mi t khai dn 1 nh vo khung, 2 nh ri.
(2) Ghi c th: ngh cp h chiu ln u; cp li h chiu (do mt/ ht hn/ tch cp
ring h chiu cho con); cp i h chiu; thay i h v tn, ngy thng nm sinh, s
giy CMND trong h chiu; b sung con di 14 tui vo h chiu ca cha/ m; sa i
ni sinh trong h chiu; ngh khc nu c (ghi r l do).
(3) Trng Cng an x, phng, th trn ni thng tr hoc tm tr xc nhn i vi cc trng
hp gi h s qua ng Bu in v trng hp l tr em di 14 tui.
Trng hp y thc cho c quan, t chc c t cch php nhn np h s th Th trng c
quan, t chc xc nhn.