Mu 3

(Mu ng vin t bo co thc hin Q 76 ca TW v CT 14 ca Thnh y)

NG B THNH PH HI AN
NG B .
CHI B .
*

NG CNG SN VIT NAM

BN T BO CO
V tham gia sinh hot v gi mi lin h vi cp u ni c tr
Nm ............
- H v tn
:
.....................................................................................
- Chc v
: .....................................................................................
- n v cng tc : .....................................................................................
- Ni c tr: Thn/khi ph.........................................................................
X/phng..............................................................................
Ti xin trnh by nhng u, khuyt im v vic thc hin nhim v
ng vin v ngha v cng dn ni c tr theo Quy nh 76-Q/TW ngy
15/6/2000 ca B Chnh tr v Ch th 14-CT/TU ngy 01/6/1999 ca Ban Thng
v Thnh y nh sau:
I/ u im v nhng vic lm c:
1/ Chp hnh v vn ng ngi thn chp hnh v thc hin ch
trng, ng li, chnh sch ca ng, php lut ca Nh nc v cc quy
nh ca a phng trn a bn c tr:
...
..
....

...
..
.
2/ Xy dng gia nh vn ho v thc hin ngha v cng dn ni c tr:
...
..
....

...

3/ o c, li sng; mi quan h vi nhn dn, vi cp y ni c tr:

(Mu ng vin t bo co thc hin Q 76 ca TW v CT 14 ca Thnh y)

...
..
....
..
.
II/ Nhng khuyt im tn ti v nhng vic cha lm c:
...
..
.

.
Hi An, ngy.. thng. nm ........

Ngi t bo co

PHN NHN XT CA CP Y NI C TR:

TT

Thc hin nhim v

Bn thn v gia nh thc hin ngha v cng

dn, cng tc x hi, cc quy nh ni c tr

Quan h vi nhn dn, vi cp y ni c tr

Vn ng gia nh xy dng gia nh vn ha

Bn thn v gia nh tham gia sinh hot, hi hp

ti khu dn c (hoc do chi y triu tp)

Tt Kh

Trung Cha
bnh
tt

*nh gi chung:
+ V gi mi lin h vi cp y ni c tr v thc hin ngha v cng dn ni
c tr ( Tt, Kh, TB, Cha tt):
+ Xy dng gia nh vn ha (t, Khng t):..
*Nhng vn cn phn nh, trao i thm (nu c):

(Mu ng vin t bo co thc hin Q 76 ca TW v CT 14 ca Thnh y)

Xc nhn ca ng y x/phng:

T/M BAN THNG V

T/M CHI Y