CQNG HOA xA HQI CHU NGHiA VIJI;T NAM

Dl}cI~p - T,! do - HlJnh phUc

Anh 3x4

sa YEU L Y LJCH
Phan 1- Ljch sU'ban thiin

1- HQ va ten:
2- Nam, nlJ:.
3- Nga~, tha~g, pam, sinh:
::
:
~
4- Thuang tm so nha:
duang:
Phuang, xa:
..................................
Qu(in (Huy~n):
5- Dan tQc:
6- Ton giao:
7- Ngay tham gia t6 chuc (nong hQi, ph\! nit, cong doan):
..................................
t\li
8- Ngay vao Doan Thanh nien CQng san Hd Chi Minh:
t\li:
'
. D'ang C. V"t
.
vao
Qng san
1 Nam:
t\ll:
9- Ngay
10- Trinh dQvan hoa:
Trinh dQdao t\lOchuyen mon nghi~p V\l:
nam t6t nghi~p:
11- Qua trinh hO\lt dQng ban than (tom t~t tir 12 tu6i d~n nay, lam gi? 0 dau?)

Phan II - Quan

hf gia

mnh

12- HQva ten cha:

NghS nghi~p (chuc V\!va c~p b~c) truac va sau 30/4/1975:

Ch6 6 hi~n nay:

13- HQva ten my:
NghS nghi~p (chuc V\lva

.
.
.
.
.
.
.
.
.
.
.

Sinh nam:

.
.

Sinh nam:

.
.
.

..............................................................................................................................

..

dp b~c) truac

va sau 30/4/1975:

................................................................................................................................
..............................................................................................................................

Ch6 a hi~n nay:

14- HQ va ten vq (ho~c ch6ng):
NghS nghi~p (chuc VI) va c~p b~c) truac va sau 30/4/1975:

..
.
.
.

Sinh nam:

...............................................................................................................................
..............................................................................................................................
...............................................................................................................................
..............................................................................................................................

..

..........................................................

.
.

...............................................................................................................................

Ch6 a hi~n nay:

15- HQ va ten cae con: Tu6i, lam gi,

a dau?

................................................................................................................................

............................................................................................................................... .
............................................................................................................................... .

...............................................................................................................................

............................................................................................................................... .
16- HQ va ten anh, chi, em ruQt: Tu6i, lam gi,

a dau?

................................................................................................................................
...............................................................................................................................
..............................................................................................................................
...............................................................................................................................

Ngay

thang

.
..
.

nam 201...

N guM khai

(kY ten)

Hr ten:

vA CHUNG NH~NCVA UBND xA, PHUONG NaI CU TRU

HO~C CO QUAN, TO CWC NaI DANG CONG TAc
NQi dung chUng nh~n c~n ghi ban Ii Ijch nay dung hay sai. N~u sai thi ghi fa sai
a ch6 nao (co th nhgn xet v tu each ngh nghi~p va hoan canh)
NH~NXET

Ngay

thang

nam 201...