Mu 29

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

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

..
1

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

S:

/GXNTH-.

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc

...2, ngy

thng

nm 20

GIY XC NHN QU TRNH THC HNH

.......................3 xc nhn:
ng/b: ...........................................................................................................
Ngy, thng, nm sinh: ...................................................................................
Ch hin nay: 4............................................................................................
Giy chng minh nhn dn/H chiu s:...................Ngy cp:.......... Ni cp:
.............................
Vn bng chuyn mn: 5.......................... Nm tt nghip: .............................
thc hnh ti 6.................................................. v t kt qu nh sau:
1. Thi gian thc hnh: 7.
2. Nng lc chuyn mn: 8..
Trong thi gian cng tc khng c vi phm o c ngh nghip.
Ti hon ton chu trch nhim v xc nhn ny./.
TH TRNG N V
(K tn v ng du)

1. Tn c s khm bnh, cha bnh.

2. a danh
3. i din c s khm bnh, cha bnh.
4. Ghi r a ch theo ni ng k thng tr hoc tm tr
5. Ghi theo n ca ngi ng k thc hnh.
6. Ging nh mc 2
7. Ghi c th thi gian thc hnh t ngy.... thng...nm.... n ngy.... thng....nm...
8. Nhn xt c th v kh nng thc hin cc k thutchuyn mn theo chuyn khoa ng k thc hnh