Mu s: D01b-TS

(Ban hnh km theo Q s:1111 /Q-BHXH

ngy 25./10/2011 ca BHXH Vit Nam)

CNG HA X HI CH NGHA VIT NAM

n v:..........
S:.....................

c lp - T do - Hnh phc
................, ngy ..... thng ..... nm ...........

Knh gi: Bo him x hi.............................................

- Tn n v:..................................................................................................
- M s qun l:.............................................................................................
- a ch:........................................................................................................
Ni dung:
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L do:
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H s gi km:
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ngh c quan bo him x hi xem xt, gii quyt theo quy nh.
Th trng n v
(k, ng du v ghi r h tn)

Tn n v:...........................
M s:...................................

DANH SCH NGH

(Km theo cng vn s:.................... ngy......................)
STT

H v tn

M s

Ni dung ngh

Mi

Cn c iu chnh