Mu s: TK1-TS

(Ban hnh km theo Q s:

/Q-BHXH
ngy ........./..../...........ca BHXH Vit Nam)

BO HIM X HI VIT NAM

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

T KHAI THAM GIA

BO HIM X HI, BO HIM Y T

S nh danh: 2 7 1 4 0 0 9 0 0 3
A. THNG TIN CA NGI THAM GIA:

[01]. H v tn (vit ch in hoa): V TH THU H

1 5

[02]. Ngy thng nm sinh:

[03]. Gii tnh: Nam

0 9

1 9 9 1

X [04]. Dn tc: Kinh

[05]. Quc tch: Vit Nam.

[06]. Ni cp giy khai sinh (qu qun): [06.1]. X, phng: Minh Tn

[06.2]. Qun, huyn: Kinh Mn

[06.3]. Tnh, TP: Hi Dng

[07]. Thn nhn

[07.1]. Cha hoc M hoc Ngi gim h: Cha: V Vn c (Sinh nm 1967).
[07.1]. Thn nhn khc: .
[08]. S chng minh th (H chiu):
[08.1]. Ngy cp:

1 9

0 9

1 4 2 5 2 4 5 4 5
2 0 0 6

[08.2]. Ni cp: Cng an Hi Dng

[09]. a ch ng k h khu: [09.1]. S nh, ng ph, thn xm: .

[09.2]. X, phng Minh Tn [09.3]. Qun, huyn: Kinh Mn [09.4]. Tnh, TP: Hi Dng
[10]. a ch lin h (ni sinh sng): [10.1]. S nh, ng ph, thn xm: Chung c Xun
Mai Tower, ng T Hiu
[10.2].X, phng: H Cu [10.3].Qun, huyn: H ng [10.4].Tnh, TP: H Ni
[11]. S in thoi lin h: 0935.813.893

[12].Email: thuha.vu.1991@gmail.com

[13]. Ni ng k khm cha bnh ban u: Bnh vin YHCT H ng.

B. THAM GIA BO HIM X HI, BO HIM Y T:
I. CNG THAM GIA BO HIM X HI BT BUC, BO HIM Y T

[14]. Quyt nh tuyn dng, hp ng lao ng (hp ng lm vic): s 567/Q-LDK

ngy 28/ 07/ 2015 c hiu lc t ngy 03/ 07/ 2015. loi hp ng: Xc nh thi hn 12
thng
[15]. Tn c quan, n v: Tng Cng ty in lc Du kh Vit Nam.
[16]. Chc v, chc danh ngh, cng vic: Chuyn vin Ban Thng mi- Tng Cng ty
in lc Du kh Vit Nam
[17]. Lng chnh: 2.34

[18]. Ph cp: [18.1]. Chc v............., [18.2]. TN

vt khung ...., [18.3]. TN ngh .., [18.4]. Khc ....

II. THAM GIA BO HIM X HI T NGUYN

[19]. Mc thu nhp thng ng bo him x hi t nguyn: ..

[20]. Phng thc ng: ..
III. CH THAM GIA BO HIM Y T

[21]. Tham gia bo him y t theo i tng: .

[22]. Mc tin lm cn c ng bo him y t:
[23]. Phng thc ng:
Ti cam oan nhng ni dung k khai l
ng v chu trch nhim trc php lut v
nhng ni dung k khai.
.........., ngy ....... thng ....... nm ...........
Ngi khai
(K, ghi r h tn)

PH LC: THI GIAN LM VIC C NG BHXH

CHA HNG MT LN
T
thng
nm

n
thng
nm

Din gii

Cn c
ng

T l ng (%)
BHXH BHTN
5

PH LC: NGI CNG THAM GIA BO HIM Y T

S

T
T

H v tn

Ngy thng
nm sinh

N
(X)

M s

Quan h
6

a ch thng tr
hoc tm tr

Ni ng k
KCB ban u

Thng nm ng
BHYT
T

10

Ghi ch
11