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I HC QUC GIA TP.

HCM

CNG HA X HI CH NGHA VIT NAM


c lp T do Hnh phc

TRNG I HC
CNG NGH THNG TIN

Tp. H Ch Minh, ngy thng

nm

N NG K MN HC
Knh gi: Phng o to SH&KHCN
H v tn:............................................................

Kha hc: .............................

MSHV: ......................................... Hnh thc hc:..............................................


Email:............................................ S in thoi lin lc.....................................
ng k d hc ln th:............... Mn hc: ......................................................
...............................................................................................................................
Ging vin ph trch:............................................................................................
Thi gian hc:...................................................... t chc cho kha: ...........
L do: ....................................................................................................................
...............................................................................................................................
thanh ton hc ph, ngy*:............................ bin lai thu s:........................
...............................................................................................................................
Ti xin cam kt chp hnh ng cc qui ch v quy nh ca Nh trng.
kin Phng TSH&KHCN

.Ngy..thng..nm..
Hc vin k v ghi r h tn

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

* Nu d hc ln th nht: minh chng ng hc ph ca kha hc theo quy nh,


Nu hc li do cc ln hc trc cha t: minh chng bin li thu hc ph i vi
mn ng k hc li ln ny.

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