GIY YU CU BI THNG

(PTI CARE)
Tn ch hp ng bo him:

NAM

CNG TY TNHH FUJIKURA FIBER OPTICS VIT

Tn Ngi c bo him:
H Hu Cng
Sinh ngy: 06/08/1990
M s nhn vin:
Email:
cuonghh@vn.fujikura.com
in thoi:
Ngi thn ca nhn vin : H Nhc Bch Nguyn

10508
0901550945

I.Thng tin thanh ton: Vui lng lit k cc chng t v ha n gc km theo mu ny:
Chng t y t

Ha n thanh ton

1 Ha n gi tr gia tng: Khm bnh + CT

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1. Ha n
VND

1.700.000

2.Ha n
VND

.:

4. Ha n
VND

.:

4 5 Ha n
5. VND
Tng cng
VND

.:
1.700.000

II.Hnh thc nhn tin

Nhn tin mt
Ngi th hng:

S CMND:

Ngy cp: Ni cp:

a ch nhn tin:

Chuyn khon
Ngi th hng: H Hu Cng
S ti khon:
0381000399182
Tn Ngn hng:
Vietcombank
Chi Nhnh:.
a ch.

III.Cam kt
Ti, vi t cch l ngi yu cu bi thng, xin cam oan nhng li khai trn l ng s tht. Ti
cng ng rng vi Giy yu cu ny, ti cho php PTI tip xc vi cc bn th ba (t bt k
bc s, c s y t, nh thuc, Cng ty v cc i l hoc cc t chc khc...) thu thp thng tin
cn thit nhm xem xt bi thng cho hp ng bo him ca ti.
Ngy: 24/08/2015

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him

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