CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc

Dn nh 3 x 4
v ng du
gip lai

S YU L LCH
T THUT

H v tn: ..................................................................................nam, n:...........................

Sinh nm:.............................................................................................................................
Ni ng k h khu thng tr hin nay:..........................................................................
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Chng minh th nhn dn s:..........................................cp ti:........................................
Ngy...............thng...................nm.....................
Khi cn bo tin cho ai, u?
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S .............
K hiu ........................
H v tn:...................................................................................b danh:...................................
Tn thng gi:..........................................................................................................................

Sinh ngy.................thng...............nm.............ti:................................................................
Ni ng k thng tr hin nay:.............................................................................................
Dn tc:............................................................................tn gio:...........................................
Thnh phn gia nh sau ci cch rung t (hoc ci to cng thng nghip) .....................
Thnh phn bn thn hin nay:.................................................................................................
Trnh vn ha:.........................................................trnh ngoi ng:..............................
Kt np ng Cng Sn Vit Nam................................................thng...............nm............
Ni kt np:...............................................................................................................................
Kt np on thanh nin Cng sn H Ch Minh ngy................thng...............nm.............
Ni kt np:................................................................................................................................
Tnh trng sc khe hin nay: ..................................................................................................
Ngh nghip hoc trnh chuyn mn:..................................................................................
Cp bc :..........................................................................lng chnh hin nay:......................
Ngy nhp ng QNDVN (TNXP).................................ngy xut ng...................................
L do:........................................................................................................................................

HON CNH GIA NH

H tn b:......................................................tui............ ngh nghip....................................
on th tham gia:
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T nm 1955 n nay lm g ? u ? ( ghi r tn c quan, x nghip hin nay ang lm)
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H v tn m:.................................................tui...........ngh nghip......................................
on th tham gia:
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T nm 1955 n nay lm g ? u ? ( ghi r tn c quan, x nghip hin nay ang lm)

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H V TN ANH CH EM RUT
( Ghi r tn, tui, ngh nghip v trnh chnh tr ca tng ngi)
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H v tn v hoc chng:..........................................................................tui.........................
Ngh nghip:.............................................................................................................................
Ni lm vic:.............................................................................................................................
Ch hin nay:.........................................................................................................................

QU TRNH HOT NG CA BN THN

T thng nm n
thng nm

Lm cng tc g?

u?

KHEN THNG V K LUT

Khen thng:.............................................................................................................................
K lut:......................................................................................................................................

LI CAM OAN
Ti xin cam oan nhng li khai trn l ng s thc, nu c iu g khai man ti xin
chu trch nhim hon ton.
Xc nhn ca Th trng C quan
X nghip, Ch tch UBND X,
Phng

Ngy..... thng..... nm 200.....

Ngi khai k tn