CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

L LCH VN NG VIN
MN TH THAO:.......................................

1. H v Tn:...........................................................................................Nam N
2. Ngy thng nm sinh:.......................................................Ni sinh:..................................
3. Dn tc:............................................................................ Tn gio:.................................
4. Qu qun:.........................................................................................................................
5. S CMND:.....................................Cp ngy:............................Ni cp:..........................
6. a ch thng tr:.............................................................................................................
7. Vn ng vin thuc Trung tm TDTT qun, huyn:..........................Khc:....................
8. Trnh chnh tr: ng vin on vin ; Ngy kt np:........................
9. Trnh :
Vn ho:.....................................................................................................................
(ghi r cp bc, trng lp ang theo hc.)

Chuyn mn:..............................................................................................................
10. Trnh ngoi ng::........................................................................................................
Bng cp (chng ch):................................................................................................
Kh nng: nghe ni c vit

11. Hon cnh gia nh:.........................................................................................................

Tn cha:....................................................................Nm sinh:.................................
Qu qun:...............................................................Ngh nghip:..............................
Tn m:....................................................................Nm sinh:..................................
Qu qun:...............................................................Ngh nghip:..............................
S in thoi lin lc:.....................................Email:.................................................

12. C kh nng, iu kin tp hun di hn ngoi TP. H Ch Minh:

Tp trung trong nc di hn
Tp trung nc ngoi di hn
Khng

1
13. Khen thng:
Cp Nh nc:....................................................................................Nm...............
Cp U ban TDTT:.............................................................................Nm...............
Cp Thnh ph:..................................................................................Nm................

14. Thnh tch:

NmGiiHuy chngNi dung..
ng cp: ..
NmGii.Huy chngNi dung.
ng cp
ng cp: ..
15. Qu trnh t p luy n:
T nm.. n nmi..... nv.
T nm.. n nmi..... nv.
T nm.. n nmi..... nv.
T nm.. n nmi..... nv.

Thnh ph H Ch Minh, ngy thng nm

Xc nhn ca n v (Chnh quyn) Vn ng vin (K, ghi r h tn)