Mu s:01/06-BNG/LS//TKHC

B NGOI GIAO

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc
--------------------------------------

-Np 03 nh, c 4x6cm,

phng nn mu sng,
mt nhn thng, u
trn, khng eo knh
mu, o mu sm.
- nh chp cch y
khng qu 1 nm.
- Dn 1 nh vo khung
ny, ng du gip lai
vo nh.

T KHAI
CP H CHIU CNG V V H CHIU NGOI GIAO

H v tn (ch in): . . . . . . . . . . . . . . . . . . .
Sinh ngy: . . thng . . nm . . .
Nam . . . N . .
Ni sinh: . . . . . . . . . . . . . . . . . . . . . . .

H khu thng tr: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Giy chng minh nhn dn s: . . . . . . . . . cp ngy: . / . / . . ti: . . . . . .
Ngh nghip: . . . . . . . . C quan cng
tc: . . . . . . . . . . . . . . . . . .a ch c quan: . . . . . . . . . . . . .
. . . . . . . in thoi: . . . . . . . Chc v: . . . . . . . . . . . . . . . .
Cp bc, hm (lc lng v trang): . . . . .
Cng chc/vin chc*: Loi: . . . . Bc: . . . . Ngch: . . . . . . . .
c cp h chiu Ngoi giao s: . . . . . . . cp ngy: . / . / . . ti: . . .
hoc / v h chiu Cng v s: . . . . . . .
cp ngy: . / . / . . ti:. . . . .
Nay i n nc: . . . . . . . . . . . . . . Qu cnh nc: . . . . . . . . . . .
Mc ch chuyn i: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
D nh xut cnh ngy: . / . / 200 .Thi gian lm vic nc ngoi: . . . . . . . .
S th t: . . trong Vn bn c i nc ngoi s: . . . . . . , ngy . / . / 200 ;
H v tn ngi k Vn bn c i nc ngoi : . . . . . . . . . . . . . . . .
Gia nh

H v tn

Nm sinh

Ngh nghip

a ch

Cha
M
V/chng
Con
Ti xin cam oan nhng li khai trn l ng s tht v xin chu hon ton trch nhim trc php lut.
Lm ti . . . . . , ngy
thng
nm 200 .
Ngi khai
(K v ghi r h tn)
XC NHN
(Th trng c quan/n v ni ngi ngh cp h chiu ang cng tc (nu l ngi thuc bin ch nh
nc) hoc Trng Cng an phng (x) ni ng k h khu thng tr hoc tm tr di hn (nu l ngi
khng thuc bin ch ca c quan Nh nc) xc nhn nhng li khai trn l ng s tht v ngi ngh
cp h chiu iu kin c xut cnh).

.
(K,

. , ngy
thng nm 200 .
ghi r h tn, chc v, ng du)

2
*Loi: V d: A3, A2, A1,Ao, B, C1,C2,C3.
Bc: V d: 2/6.., 3/8.., 1/9..,2/10.,5/12...
Ngch: Vd: Chuyn vin, nhn vin, k thut vin