Mu 02

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc
.............................. 1, ngy....... thng..... nm 20.....
N NGH
Cp li chng ch hnh ngh khm bnh, cha bnh
Knh gi: S Y t tnh ng Thp.
H v tn:................................................................................................................
Ngy, thng, nm sinh: ...........................................................................................
a ch ng k h khu thng tr:2 .....................................................................
.................................................................................................................................
Giy chng minh nhn dn s: ..................................., Cp ngy......../....../..........
Ni cp:.....................................
in thoi:.............................................. Email (nu c): .....................................
Vn bng chuyn mn: 3..........................................................................................
S chng ch hnh ngh c:............../.........-CCHN, Ngy cp:..............................
Ni cp: ....................................
L do ngh cp li:
1. Do b mt

2. Do b h hng

3. Do b thu hi

Knh ngh Qu c quan xem xt v cp li chng ch ti c hnh ngh

khm bnh, cha bnh./.
NGI LM N
(K v ghi r h, tn)

1. a danh.
2. Ghi r a ch theo ni ng k thng tr hoc tm tr.
3. Vn bng chuyn mn ghi theo i tng: Bc s, Y s, iu dng vin, H sinh vin, K thut vin, Lng
y, Giy chng nhn bi thuc gia truyn hoc Giy chng nhn phng php cha bnh gia truyn.