T chc Khoa hc & Gio dc

"Gp g Vit Nam"

Association "Rencontres du Vietnam"
104 Avenue du Gnral Leclerc
91190 Gif sur Yvette, France
Vn phng iu phi ton quc
37 L Ng Ct, TP Hu
T: (054) 3931093 * D: 0914 156 606

PHIU NG K HC BNG VALLET

(Dnh cho SINH VIN CAO HC)
1. H v tn (1):........................................................................................................................................
Ngy thng nm sinh:..................................................................ti....................................................
Sinh vin nm th:............. Trng.....................................................................................................
a ch lin lc (2):................................................................................................................................
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2. Thng tin v gia cnh
H v tn Cha :.......................................................Nm sinh.............Ti............................................
Ngh nghip:................................................................................................................
H v tn M :....................................................... Nm sinh.............Ti............................................
Ngh nghip:................................................................................................................
L con th my trong gia nh :...........................................................................................................
S anh ch em: .....................................................................................................................................
3. Thng tin v hc vn
Tt nghip i Hc ngnh (3): ....................................nm....Xp loi:...................
Khoa :...................................................................Trng....................................................................
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4. ti Nghin cu Khoa hc
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(1)

Vit bng ch in hoa

Ghi r cc thng tin: a ch, s in thoi, a ch e-mail
(3)
Ph t vn bng, bng im 4 nm i Hc
(2)

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5. nhn Hc bng Vallet ln no cha (nu c, nhng nm no?):................................................
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Ti xin cam oan nhng thng tin k khai trn l ng s tht.

Xc nhn ca Gio s Hng Dn

Hu, ngy.thng..nm 2012

Sinh vin k tn