CNG HO X HI CH NGHA VIT NAM

c Lp T Do Hnh Phc

S YU L LCH
PHN I : LCH S BN THN
1. H v tn : ..................................................................., Nam/ N:.....................................
2. Ngy, thng, nm sinh :

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

3. H khu thng tr: S nh ................ p ................................ X (Phng).....................................

Huyn(Qun)...................................Tnh (Thnh ph)..............................................................................
4. Dn tc: ............................., Tn gio:............................
5. Trnh hc vn: .............................................
6. Trnh chuyn mn : .......................................................
7. Trnh ngoi ng : Anh vn (chng ch) ............................................................
Php vn (chng ch)...........................................................
8. Trnh tin hc: ................................................................
9. Ngy vo on TNCS H Ch Minh :
10. Ngy vo ng Cng sn Vit Nam :

/
/

, ti ............................................
/

, ti ...........................................

11. Qu trnh bn thn:

Tm tt qu trnh hc tp v lm vic t 12 tui n nay

PHN II : QUAN H GIA NH

12. H tn Cha : .........................................................

sinh nm : ....................

- Ngh nghip : .............................................

- Tm tt qu trnh bn thn :
+ Trc 1975: ..........................................
+ Sau 1975 : ........................................................................................................
- Ch hin nay : ............................................................................................................................
.....................................................................................................................................................................
13. H tn M : .........................................................
- Ngh nghip : ............................................
- Tm tt qu trnh bn thn :

sinh nm : ......................

+ Trc 1975 : .....................................................................................................

+ Sau 1975 : ........................................................................................................
-

Ch hin nay : .......................................................................................................................

........................................................................................................................................................
14. Anh ch em rut : (ghi r h tn, nm sinh, ngh nghip, ni hin nay)
15. V (chng): (ghi r h tn, nm sinh, ngh nghip, ni hin nay)
16. Con: (ghi r h tn, nm sinh, ni hin nay)
Ti xin cam oan li khai trn l ng.
Ngy ..... thng ...... nm 2010
Ngi khai
( K tn v ghi r h tn)

NHN XT V CHNG NHN

CA CHNH QUYN A PHNG