MAu 1.2/TS.

SYLL

ceNG HoA xA ugr cnu NcninvrTT NAM

DQc lflp - Tq do - Hgnh phric

so YEU r,.f r,1Crr Anh mdu

cd (4x6)
f. VG nfln thOn:
hoa):.........
H9 vd t€n (vi6t chtr in Gi6i tinh: Nam/Nt
Sinh ngdy, thhng, nim:.......... .. Noi sinh (tinh/Tp)
Don vi cdng t6c:....
Chric w hi6n t4i:
Noi cujtru: Sij nhd, dunng ph6, xd/phudng, huyQn/quQn, tinh/thdnh ph6

HQ khdu thucrng tru:

Dia chi li6n h6:

..kg
SO CVINO (Cdn cu6c c6ng ddn)... .......,.r....:-j:. cap
A
l\gay cap:
Qur[ trinh hgc tflp vd cdng tric:
Tri ngdy d6n ngdy Noi hpe t4p, cdng t6c vd chirc vU dugc dim nhiQm

ii:::::
.:::a::

rii
.rll:i'

iii ii;,iil,ll
lii,,,,iil

tt ':'

X5c nhfn cira Co quan nhd nu6c c6 thAm quy6n

r ............, ngdy thdng ndm 20
i (N4adi khai lry, ghi rd hp t€n)