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BO HIM X HI VIT NAM

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
Mu s: A01-TS
(Ban hnh km theo Q s: 1111/Q-BHXH
Ngy 25/10/2011 ca BHXH Vit Nam)

T KHAI THAM GIA


nh
3x4

BO HIM X HI, BO HIM Y T

M s: __________________________

I. THNG TIN CA NGI THAM GIA:

[01]. H v tn (vit ch in hoa):_NGUYN NH HU , [02]. Gii tnh: Nam


N
[03]. Ngy thng nm sinh: 19/09/1988 , [04]. Dn tc: Kinh, [05]. Quc tch: Vit Nam
[06]. H khu thng tr hoc tm tr:_Lc Hng, Vn Lm, Hng Yn______________
[07]. a ch lin h:_ Trn Thi Tng, Cu Giy, H Ni__________________________
[08]. S in thoi lin h (nu c): c nh: ________________, di ng: _097 5678 038_____
[09]. CMT s:145240041_______, ngy cp:_31/07/2003____, ni cp:_Cng an Hng Yn_
II. THAM GIA BO HIM X HI BT BUC, BO HIM Y T:

[10]. Quyt nh tuyn dng, hp ng lao ng (hoc HLV): s___________________


ngy ___/___/_____ c hiu lc t ngy ___/___/_____ loi hp ng _______________
[11]. Tn c quan, n v, a ch: __Cng ty C phn nh Sng Xanh_____________
________________________________________________________________________
[12]. Ni lm vic:_________________________________________________________
[13]. Chc v, chc danh ngh, cng vic: ______________________________________
________________________________________________________________________
[14]. Lng chnh: ___________________________,
[15]. Ph cp: [15.1]. PCCV___, [15.2]. TNN____, [15.3]. TNVK____, [15.4]. Khc ____
[16]. M s s bo him x hi c cp (nu c):_______________________________
[17]. M s th bo him y t c cp (nu c):________________________________
[18]. Ni ng k khm cha bnh ban u (theo hng dn ca c quan BHXH): ____________
________________________________________________________________________
[19]. Quyn li hng bo him y t (nu c):_____________________________________
Xc nhn ca ngi s dng lao ng
Ti xin cam oan nhng ni dung k khai Sau khi kim tra, i chiu xc nhn cc ni
trn l ng s tht v xin chu hon ton dung k khai trn l ng v xin chu hon
trch nhim trc php lut.
ton trch nhim trc php lut.
.........., ngy ....... thng ....... nm ...........
.........., ngy ....... thng ....... nm ...........
Ngi khai
Th trng n v
(K, ghi r h tn)
(K, ghi r h tn v ng du)
Duyt ca c quan bo him x hi:
Cn b thu
(K, ghi r h tn)

Cn b s, th
(K, ghi r h tn)

........., ngy...... thng...... nm .........


Gim c BHXH
(K, ghi r h tn v ng du)

PH LC: THI GIAN LM VIC C NG BHXH


CHA HNG MT LN
T
thng
nm

n
thng
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T l ng (%)

Din gii

Cn c
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BHXH

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