BM.08.

01
15.05.2004

CNG HA XA HI CHU NGHIA VIT NAM

c l p T do Hanh phuc

N XIN XAC NHN HANH KIM

Kinh gi: Cng an Phng (Xa):........................................
Qu n
(Huy n
:).....................................................
Ti tn la: ...................................................................................................................
Ngay, thang, nm sinh: ...............................................................................................
Ni sinh: ....................................................................................................................
Nguyn quan: ...................................................... Dn t c:.......................................
a ch thng tru: .....................................................................................................
a ch tm tru: ...........................................................................................................
S CMND / H chiu: ..............................................................................................
Cp ngay: ............................................. Ti:............................................................
Knh mong Cng an phng (x) xac nhn v hnh kim ca ti: t trc n nay
bn thn ti khng c vi phm phap lut, khng c tin an tin s, cng nh khng
c vi phm v an ninh trt t ti a phng.
L do b tuc h s: xin vic lam.
.................., ngay . . . thang . . . nm 20
Kinh n

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PHN XAC NHN CUA CNG AN

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