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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    60 views1 page

    Mẫu Điền Biểu Mẫu x01

    Uploaded by

    naypcuoi
    tai 1

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    MiuTorm XOI

    B a n hnh k m theo T h n g t s 0 7/2013/T T -B C A


    n g y 30 th n g 01 n m 2013

    c' C| W h a x h i c h n g h a v i t n a m nh
    i t " M ^ ^ 9 C 1$ - T do - H n h phc mi chp, c
    4x6 cm, ni nhn
    thng, u
    T KHAI trn, khng eo
    (Dng cho cng dn Vit Nam d ngh cp, knh mu,
    sa i h chiu ph thng trong nc) phng ncn trng,
    p
    ()

    1. H v tn (ch in hoa) ................. A i .G . y .tM ........ V . N ....A )\i. ................................ 2 Na


    Nam 0 N
    3. Sinh n g y . c u .. thng..O ..tm ...J Q . Ni sinh (tnh, TP)...............h p n h ... d o o .............................
    4. G iy CMND s B j \0 \ 5 \> \ i 16 B Z E E (2)N gy c ol . . i . . 3 . . Ni cp (tnh, T P ).M ^.h.J r/
    5*Dn ..................
    ........................... 6. Tn gio
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    .......7.7. S"in O0.Q.
    S in thoi....... Q . . S M Z . ...........
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    Q P l i o /> ll? t k i n i _________ ?
    ''7' /
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    8. a ch thng tr (ghi
    'M theo s h khu).....j,%..>
    n
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    ^ .: H. ) . t
    . '
    . i 'T I ^ r. / f - / /I . - i

    .........................................S .....f? .k...


    n (}.....)?.h . . . . 7 f n f .. ....r h k ... J / h .... i/.
    9. a ch tm tr (ghi theo s lm tr)

    10. N gh nghip. Q ,. m A / ..J o .....II. Tn v a ch c quan (nu c)...................................................

    12. Cha: h v t n .....j 'a u ^ io ....M.d.o... . m .b ........................................ sinh ngy. / /. J M . .


    M: h v t n ....... 7 M n ....../.....h.0.C.......................................... sinh ngay............./ . . ......./ J . i V
    V / chng: h v tn.. ....T h... M a i... M n .......................... sinh ngy............ / .........../. J M
    13. H chiu PT c cp ln gn nht (nu C) s.....d / c .c d b y ngy.........../ /
    14. Ni dung n g h (3)...........C p ... .- . . c k m . . ... J ..... y . i.........................
    nh
    15. Con di 9 tui ngh cp chung h chiu {nu c): m i chp,
    m t nhn thng,
    H v tn (ch in hoa)................................................................. Nam N u Irn,
    Sinh ngy.........thng......... n m ................... Ni sinh (tnh, TP) ........................................ p h n g n n Irng
    c 3x4 cm
    r i xin chu trch nhim trc php lut v li khai trn. ( 1)
    Xc nhn f
    ca Trng Cng an x/ phng/ th lr n W Lm t i.x h . h ... . ngy.Q,. thng. ,3 ...nm,J.Q
    hoc Th trng Cquan, t chc, doanh nghip c y thc N g i n gh
    (K, ghi r h tn, chc v, ng du) (K, ghi r h tn)

    PHN DNH CHO c QUAN QUN L XUT NHP CNH

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