ប្រវត្តិរូបសង្ខេប

ពះ ច កកម
កសួងអប់រ យុវជន និងកី តិ ស ពះម ក ត
អង ព .................................. 
បវតិរ ូបសេងប
១- ម តកូ ល និង មខួនៈ .................................... អក រពុ ម ំងៈ ..............................................
េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

រូបថតថី
២-ៃថែខ ំ កំេណតៈ ........................../.........................../........................
4x6
៣-ទីកែនងកំ េណតៈ ភូមិ....................................................ឃុំ/ស ត់....................................................
សក/ខណ/ កង......................................... ជ នី/េខត......................................
៤-ក មិ តវប ធម៌ទូេ ៈ .......................................................សម័យ បឡង............/................./...............
៥-ក មិ តឧតមសិក ៈ
ក- មិតឧតតមសិក ឯកេទស ទី កែនងបណុ ះប ល ៃថែខ ំ ប់ េផ ម ៃថែខ ំប ប់
៦-ក មិ តវ ិ ជីវៈ
េ ះក មិតវ ិ ជី វៈ ឯកេទសទី១ ឯកេទសទី២ ទីកែនងបណុ ះប ល ៃថែខ ំ នទទួល
៧-ជំ ញេផ ងៗនិង ែដល នសិក បែនមៈ
េ ះជំ ញេផ ងៗនិង រយៈេពល

ទី កែនងបណុ ះប ល ៃថែខ ំ ប់េផ ម ៃថែខ ំប ប់
គិត ៃថ
៨-ៃថែខ ំចូលបេ ម រ រៈ............................................................៩-ៃថែខ ំ ំ ងស៊ប់កុង កបខណៈ...............................................
១០-អង ពបេ ម របចុ ប នៈ...................................................ភូ មិៈ...........................................ឃុំ/ស ត់ ៈ.......................................
សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................
១១- រិ ល័យៈ............................................................................មុ ខតំែណងៈ....................................... បេភទ ំ ក់ ៈ.................
១២-ៃថែខ ំេឡង ំ ក់ ចុងេ យៈ....................../............../....................

១៣- ន ពគ រៈ េរ ប រ □ េម ៉ យ េ ះ ៉យ □ េ លីវ □
-េ ះបី បពន:...............................................................មុខរបរបី ប/ពន:................................................................................
-អង ពបី / បពន......................................................................................................................................................................
-កូន(កូន ំ ងអស់)
េ ះ េភទ ៃថែខ ំកំេណត មុខរបរ ទីកែនង
១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................
ទី កែនងៈ..................................................................................................................................................................................
- យេ ះ................................................................................... យុ.......................មុខរបរ...............................................
ទី កែនងៈ...................................................................................................................................................................................
១៥- អំពីបងបូ នបេង ត:
១៦- សយ នបចុ ប នៈ ភូមិ.................................................................ឃុំ /ស ត់ ........................................................................
សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................
េលខទូរស័ពៈ ................................................................................ឬ Email address………………………………………………………
កិ ចសន ទទួលខុស តវរបស់ មុី ខួនេលជីវ បវតិ េនះ
..............ៃថទី ...................ែខ……………. ំ២០……
..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

ី ន
ប នអង ព
អង ព .................................. 
េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

២-ៃថែខ ំ កំេណតៈ ........................../.........................../........................
4x6
សក/ខណ/ កង......................................... ជ នី/េខត......................................

គិត ៃថ
សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

-អង ពបី / បពន......................................................................................................................................................................
១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................
ទី កែនងៈ..................................................................................................................................................................................
- យេ ះ................................................................................... យុ.......................មុខរបរ...............................................
ទី កែនងៈ...................................................................................................................................................................................
សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................
..............ៃថទី ...................ែខ……………. ំ២០……
..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

ី ន
ប នអង ព
អង ព .................................. 
េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

២-ៃថែខ ំ កំេណតៈ ........................../.........................../........................
4x6
សក/ខណ/ កង......................................... ជ នី/េខត......................................

គិត ៃថ
សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

-អង ពបី / បពន......................................................................................................................................................................
១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................
ទី កែនងៈ..................................................................................................................................................................................
- យេ ះ................................................................................... យុ.......................មុខរបរ...............................................
ទី កែនងៈ...................................................................................................................................................................................
សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................
..............ៃថទី ...................ែខ……………. ំ២០……
..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

ី ន
ប នអង ព
អង ព .................................. 
េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

២-ៃថែខ ំ កំេណតៈ ........................../.........................../........................
4x6
សក/ខណ/ កង......................................... ជ នី/េខត......................................

គិត ៃថ
សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

-អង ពបី / បពន......................................................................................................................................................................
១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................
ទី កែនងៈ..................................................................................................................................................................................
- យេ ះ................................................................................... យុ.......................មុខរបរ...............................................
ទី កែនងៈ...................................................................................................................................................................................
សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................
..............ៃថទី ...................ែខ……………. ំ២០……
..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

ី ន
ប នអង ព

ប្រវត្តិរូបសង្ខេប

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Copyright:

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ពះ ច កកម

កសួងអប់រ យុវជន និងកី តិ ស ពះម ក ត

១- ម តកូ ល និង មខួនៈ .................................... អក រពុ ម ំងៈ ..............................................

េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

សក/ខណ/ កង......................................... ជ នី/េខត......................................

៤-ក មិ តវប ធម៌ទូេ ៈ .......................................................សម័យ បឡង............/................./...............

ក- មិតឧតតមសិក ឯកេទស ទី កែនងបណុ ះប ល ៃថែខ ំ ប់ េផ ម ៃថែខ ំប ប់

េ ះក មិតវ ិ ជី វៈ ឯកេទសទី១ ឯកេទសទី២ ទីកែនងបណុ ះប ល ៃថែខ ំ នទទួល

៧-ជំ ញេផ ងៗនិង ែដល នសិក បែនមៈ

េ ះជំ ញេផ ងៗនិង រយៈេពល

៨-ៃថែខ ំចូលបេ ម រ រៈ............................................................៩-ៃថែខ ំ ំ ងស៊ប់កុង កបខណៈ...............................................

១០-អង ពបេ ម របចុ ប នៈ...................................................ភូ មិៈ...........................................ឃុំ/ស ត់ ៈ.......................................

សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

១១- រិ ល័យៈ............................................................................មុ ខតំែណងៈ....................................... បេភទ ំ ក់ ៈ.................

១២-ៃថែខ ំេឡង ំ ក់ ចុងេ យៈ....................../............../....................

-អង ពបី / បពន......................................................................................................................................................................

េ ះ េភទ ៃថែខ ំកំេណត មុខរបរ ទីកែនង

១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................

១៥- អំពីបងបូ នបេង ត:

េ ះ េភទ ៃថែខ ំកំេណត មុខរបរ ទីកែនង

១៦- សយ នបចុ ប នៈ ភូមិ.................................................................ឃុំ /ស ត់ ........................................................................

សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................

េលខទូរស័ពៈ ................................................................................ឬ Email address………………………………………………………

កិ ចសន ទទួលខុស តវរបស់ មុី ខួនេលជីវ បវតិ េនះ

..............ៃថទី ...................ែខ……………. ំ២០……

..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

កសួងអប់រ យុវជន និងកី តិ ស ពះម ក ត

១- ម តកូ ល និង មខួនៈ .................................... អក រពុ ម ំងៈ ..............................................

េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

សក/ខណ/ កង......................................... ជ នី/េខត......................................

៤-ក មិ តវប ធម៌ទូេ ៈ .......................................................សម័យ បឡង............/................./...............

ក- មិតឧតតមសិក ឯកេទស ទី កែនងបណុ ះប ល ៃថែខ ំ ប់ េផ ម ៃថែខ ំប ប់

េ ះក មិតវ ិ ជី វៈ ឯកេទសទី១ ឯកេទសទី២ ទីកែនងបណុ ះប ល ៃថែខ ំ នទទួល

៧-ជំ ញេផ ងៗនិង ែដល នសិក បែនមៈ

េ ះជំ ញេផ ងៗនិង រយៈេពល

៨-ៃថែខ ំចូលបេ ម រ រៈ............................................................៩-ៃថែខ ំ ំ ងស៊ប់កុង កបខណៈ...............................................

១០-អង ពបេ ម របចុ ប នៈ...................................................ភូ មិៈ...........................................ឃុំ/ស ត់ ៈ.......................................

សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

១១- រិ ល័យៈ............................................................................មុ ខតំែណងៈ....................................... បេភទ ំ ក់ ៈ.................

១២-ៃថែខ ំេឡង ំ ក់ ចុងេ យៈ....................../............../....................

-អង ពបី / បពន......................................................................................................................................................................

េ ះ េភទ ៃថែខ ំកំេណត មុខរបរ ទីកែនង

១៤- ឪពុ កេ ះ :.................................................................................. យុ.......................មុ ខរបរ...............................................

១៥- អំពីបងបូ នបេង ត:

េ ះ េភទ ៃថែខ ំកំេណត មុខរបរ ទីកែនង

១៦- សយ នបចុ ប នៈ ភូមិ.................................................................ឃុំ /ស ត់ ........................................................................

សក/ខណ/ កង............................................................................... ជ នី/េខត....................................................................

េលខទូរស័ពៈ ................................................................................ឬ Email address………………………………………………………

កិ ចសន ទទួលខុស តវរបស់ មុី ខួនេលជីវ បវតិ េនះ

..............ៃថទី ...................ែខ……………. ំ២០……

..............ៃថទី...................ែខ…………. ំ២០….. ហតេល មជ

កសួងអប់រ យុវជន និងកី តិ ស ពះម ក ត

១- ម តកូ ល និង មខួនៈ .................................... អក រពុ ម ំងៈ ..............................................

េភទ ..............ជន តិ ..................ស តិ .........................កមស់ .......................

សក/ខណ/ កង......................................... ជ នី/េខត......................................

៤-ក មិ តវប ធម៌ទូេ ៈ .......................................................សម័យ បឡង............/................./...............

ក- មិតឧតតមសិក ឯកេទស ទី កែនងបណុ ះប ល ៃថែខ ំ ប់ េផ ម ៃថែខ ំប ប់

េ ះក មិតវ ិ ជី វៈ ឯកេទសទី១ ឯកេទសទី២ ទីកែនងបណុ ះប ល ៃថែខ ំ នទទួល

៧-ជំ ញេផ ងៗនិង ែដល នសិក បែនមៈ

េ ះជំ ញេផ ងៗនិង រយៈេពល

៨-ៃថែខ ំចូលបេ ម រ រៈ............................................................៩-ៃថែខ ំ ំ ងស៊ប់កុង កបខណៈ...............................................

១០-អង ពបេ ម របចុ ប នៈ...................................................ភូ មិៈ...........................................ឃុំ/ស ត់ ៈ.......................................

សក/ខណ/ កងៈ................................................. ជ នី /េខតៈ....................................................................................

១១- រិ ល័យៈ............................................................................មុ ខតំែណងៈ....................................... បេភទ ំ ក់ ៈ.................