4

Ph lc 1

Tn doanh nghip....
S.............

cng ho x hi ch ngha Vit Nam

c lp - T do - Hnh phc

n ngh cp s ng k lu hnh
trang thit b y t sn xut trong nc

Knh gi : B Y t (V Trang thit b v Cng trnh y t)

Tn c s ng k: .......................................................................................
a ch:.........................................................................................................
in thoi:....................................................................................................
Fax:..............................................................................................................
Tn trang thit b y t ng k lu hnh:......................................................
......................................................................................................................
K m hiu:...................................................................................................
H s km theo:...........................................................................................
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... , ngy... thng.... nm......
Gim c c s
(K, ghi r h tn, ng du)