CNG HO X HI CH NGHA VIT NAM

c Lp T Do Hnh Phc
nh

L LCH TRCH NGANG CBCNV

4x6

I. THNG TIN C NHN:

1. H v tn...........................................................Ngy thng nm sinh:......................................................
2. Nguyn qun:.
3. Chiu cao:..Cn nng:
4. V tr ng tuyn:
5. Ni sinh:
6. S CMND:........................................................Ni cp: CA............................Ngy cp:...................
7. Dn tc:............................................................Tn gio:.........................................................................
8. Ngy vo on TNCSHCM:............................Ni kt np:.....................................................................
9. Ngy vo ng CSVN:....................................Ni kt np:.....................................................................
10. Trnh chuyn mn:......................................Trnh ngoi ng:.........................................................
11. Ngy tham gia cc t chc Cng on/Hi:....... Ni kt np: .....................................................
12. Qu qun:...................................................................................................................................................
13. H khu thng tr:...............................................................................di ng:......................................
14. Ni ng k tm tr:..............................................................................di ng:......................................
15. Ni hin nay:......................................................................................c nh:......................................

II. QUAN H GIA NH:

1. H v tn Cha:.......................................................Ngy/thng nm sinh:.....................T:.....................
Lm g, u ?.........................................................................................................................................
Ngy vo ng CSVN:..........................................Ni kt np:.....................................................................
2. H v tn M:........................................................Ngy/thng nm sinh:.....................T:.....................
Lm g, u ?.........................................................................................................................................
Ngy vo ng CSVN:..........................................Ni kt np:.....................................................................
3. H v tn v, chng:.............................................Ngy/thng nm sinh:.....................T:.....................
Lm g, u ?.........................................................................................................................................
Ngy vo ng CSVN:..........................................Ni kt np:.....................................................................
4. H v tn Anh, Ch, Em:.......................................Ngy/thng nm sinh:.....................T:.....................
Lm g, u ?.........................................................................................................................................
.......................................................................... ..................................................... .................................
..................................................................................................................................................................
..................................................................................................................................................................
......................................................................... ..................................................... .................................
.................................................................................................................................................................
Ngy vo ng CSVN:..........................................Ni kt np:.....................................................................
5. H v tn cc Con:
STT

H v Tn

Ngy thng nm sinh

Ngh nghip

1
2
3

III. QU TRNH HC TP, CNG TC

1. Qu trnh hc tp: Khai t thi gian hc PTTH, THCN, C, H, trn H, cc kho o to ngh
T nm

n nm

Tn Trng/ T chc o to

Trnh

Chuyn ngnh

Loi TN

2. Qu trnh cng tc:

T nm

n nm

Tn C quan/ T chc
Kinh t - Chnh tr - X hi

Chc v

Ti xin cam oan nhng li khai trn l ng s tht, v hon ton chu trch nhim trc C quan v nhng
li khai cu mnh.
TP.HCM, ngy .... thng nm 2011
Ngi khai k

H v tn:..................................................................................