Mu s 02/NG-LS

(Tn C quan i din)

Ti............................
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CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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PHIU NG K CNG DN

nh 4x6

1. H v tn (ch in):..........................................................................................
2. Nam/n: .........................................................................................................
3. Ngy sinh:.......................................................................................................
4. Ni sinh:..........................................................................................................
5. Tnh trng hn nhn:.....................................................................................
6. Trnh hc vn:...........................................................................................
7. Ngh nghip: (nu l cn b nh nc ghi tn c quan)................................
8. H chiu(1): Ngoi giao Cng v Ph thng S:..............................
Ngy cp: .......................
C quan cp:...................................................
9. Mc ch lu tr ti nc s ti: :................................................................
10.Thi gian d nh lu tr ti nc s ti: ..................................................
11.a ch c tr nc s ti:.. ......................................................................
S in thoi:.............................. ................. .................................................
12.a ch thng tr Vit Nam (nu c): ....................................................
13.Tr em i cng: (ghi r h tn tui quan h vi ngi khai)........................
14.Khi cn bo tin cho ai, u? ....................................................................
Ngy ......thng..... nm....... .
(k v ghi r h tn)

======================================
Phn ghi ch ca c quan i din:
Phiu np ngy: ................. ................. ................... ................. ......................
Vo s ng k cng dn ngy: ............. Quyn s: ............. Nm:..............
S h s: ............................................ ....... Ngi vo s: (ghi r h tn).........

___________
(1). Trng hp khng c h chiu th ghi giy t c gi tr thay h chiu.

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