MU N NGH

Ph lc 5
Cp mi, i, cp li, chuyn i bng, chng ch chuyn mn
phng tin thy ni a
(B sung Ph lc 5 vo Quy nh ban hnh km theo Quyt nh s19/2008/Q-BGTVT
ngy 18 thng 9 nm 2008 ca B trng B Giao thng vn ti)
CNG HA X HI CH NGHA VIT NAM
c lp T do Hnh phc
N NGH
Cp mi, i, cp li, chuyn i bng, chng ch chuyn mn
phng tin thy ni a
Knh gi: ( C quan c thm quyn cp)
Tn ti l: ............... Quc tch: ............... ; Nam ( N)
Sinh ngy: . thng .nm...
Ni c tr:...
in thoi:.Email:
S CMND ( hoc h chiu): ..do.
cp ngy..thng..nm...
Tn dc cp bng, chng ch chuyn mn s:ngy..thng..nm..
Theo quyt nh s: .,ngy..thng...nmca
Qu trnh cng tc trn phng tin thy ni a:
TN.

CHC DANH

N V CNG TC

S PTTN

GHI CH

i chiu vi tiu chun, iu kin cp mi, i, cp li, chuyn i bng

Chng ch chuyn mn, ti thy iu kin:
+ Cp mi bng, chng ch chuyn mn:
+ i bng, chng ch chuyn mn:
+ Cp li bng, chng ch chuyn mn:
+ Chuyn i bng, chng ch chuyn mn:
ngh ( c quan c thm quyn cp) . cho ti c
cp mi, i, cp li, chuyn i bng, chng ch chuyn mn... hnh
ngh.
Ti xin cam oan nhng iu khai trn l ng s tht, nu sai tn xin hon
ton chu trch nhim./.
.,ngythng.nm.
Ngi ngh
( K,ghi r h tn)