CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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N XIN XC NHN
HON CNH KH KHN
Knh gi: UBND x, (phng):.....................................................

1. Ti tn l:............................................. Sinh ngy:......................................

2. Qu qun:.....................................................................................................
3. a ch (tm tr): ........................................................................................
..........................................................................................................................
4. Hin l sinh vin lp:................Khoa................. Trng .............................
5. M s sinh vin:...........................................................................................
6. im trung bnh hc k.............................................................im.
Xin c xc nhn gia nh ti hin ang c hon cnh nh sau:
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
..........................................................................................................................
7. Gia nh thuc din:
Chnh sch , Vng su , H ngho
Cha:...................................................tui, hin ti:.....................................
Ngh nghip: ..................................................................................................
M:.................................................... tui, hin ti:.....................................
Ngh nghip:..................................................................................................
Khc (cha m ly thn,ly d):.......................................................................
(nu mt th ghi nm v l do mt, nu bnh th ghi r bnh g, c nm
vin khng, bnh vin no? nu l thng binh th ghi r hn thng binh )

8. Gia nh canh ch em (k c ti). Ngi ln nht..............tui,

Ngi nh nht...........tui.
S ngi cn ang i hc: Cp 1:......., Cp 2:......., Cp
3:, i hc
9. Nh ti c ......m2 t trng (nui).. ......
10. Gia nh c Bun bn nh (ngh nghip khc)....
11. Thu nhp bnh qun ca gia nh.ng/thng
12. Bn thn ti: Thu nhp.ng/thng (nu c)
13. L do xin xc nhn: (VD: b sung h s xin hc bng, vay vn.)

,Ngythngnm 20....
Xc nhn ca chnh Ngi lm n
quyn a phng