Mu/Form X01

Ban hnh km theo Thng t s 07/2013/TT-BCA

ngy 30 thng 01 nm 2013

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

T KHAI
(Dng cho cng dn Vit Nam ngh cp,
sa i h chiu ph thng trong nc)

nh
mi chp, c
4x6cm, mt nhn
thng, u
trn, khng eo
knh mu,
phng nn trng.
(1)

1. H v tn (ch in hoa)................................................................................................................... 2. Nam

3. Sinh ngy.............thng............nm............... Ni sinh (tnh, TP)...........................................................................

4. Giy CMND s

(2)

Ngy cp......../......../.......... Ni cp (tnh, TP).................

5. Dn tc...............................6. Tn gio. ...................................7. S in thoi......................................................

8. a ch thng tr (ghi theo s h khu). ................................................................................................................
.......................................................................................................................................................................................
9. a ch tm tr (ghi theo s tm tr)........................................................................................................................
.....................................................................................................................................................................................
10. Ngh nghip ........................................11. Tn v a ch c quan (nu c)..........................................................
......................................................................................................................................................................................
12. Cha: h v tn ............................................................................................sinh ngy .........../............/...................
M: h v tn .............................................................................................sinh ngy.........../............/....................
V /chng: h v tn..................................................................................sinh ngy.........../............/....................
13. H chiu PT c cp ln gn nht (nu c) s.........................................cp ngy............/............/....................
14. Ni dung ngh(3) ..................................................................................................................
nh
mi chp,
15. Con di 9 tui ngh cp chung h chiu (nu c):
mt nhn thng,

H v tn (ch in hoa).. ...................................................................Nam

N
u trn,
phng nn trng
Sinh ngy.......thng.......nm............ Ni sinh (tnh, TP).....................................................
c 3x4 cm
Ti xin chu trch nhim trc php lut v li khai trn.
(1)
Xc nhn
ca Trng Cng an x/phng/ th trn(4)
Lm ti...........................ngy...... thng..... nm........
hoc Th trng c quan, t chc, doanh nghip c y thc
Ngi ngh
(K, ghi r h tn, chc v, ng du)
(K, ghi r h tn)

PHN DNH CHO C QUAN QUN L XUT NHP CNH

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Mu/Form X01

Ban hnh km theo Thng t s 07/2013/TT-BCA

ngy 30 thng 01 nm 2013

Ch thch:
(1) Dn 01 nh vo khung, 01 nh vo mt sau t khai.
(2) Nu CMND c 9 s th in vo 9 u, gch cho 3 sau; nu CMND c 12 s th in vo 12 .
(3) Ghi c th: ngh cp h chiu ln u; cp li h chiu; (do mt/ ht hn/ tch cp ring h chiu cho con) ngh iu chnh h v
tn, ngy thng nm sinh, s giy CMND trong h chiu; ngh b sung con di 9 tui vo h chiu ca m/cha; sa i ni sinh
trong h chiu; ngh khc nu c (ghi r l do).
(4) Trng Cng an phng, x th trn ni thng tr hoc tm tr xc nhn i vi trng hp gi h s qua ng Bu in v trng
hp l tr em di 14 tui. Trng hp y thc cho c quan, t chc, doanh nghip c t cch php nhn np h s th Th trng c
quan, t chc, doanh nghip xc nhn.