Mu TKXC

CNG HO 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, mt
nhn thng, u
trn, phng nn
trng, c 4x6 (1)

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

3. Sinh ngy ......thng ..... nm...........Ni sinh (tnh, TP)......................................................................
4. Giy CMND s

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 (nu c)...................................................................................................................
........................................................................................................................................................
10. Ngh nghip...................................11. Tn v a ch c quan lm vic (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 ....................................................................................
15. Con di 14 tui ngh cp chung h chiu (nu c):
H v tn (ch in hoa):............................................................ Nam N
Sinh ngy......thng.....nm......... Ni sinh ( tnh, TP)..................................
Ti xin chu trch nhim trc php lut v li khai trn.
Xc nhn
ca Trng Cng an x/ phng/ th trn hoc
ca Th trng c quan, t chc c y thc
(K, ghi r h tn, chc v, ng du)

Lm ti ................... ngy ...../ ......./...........

Ngi ngh
(K, ghi r h tn)

PHN DNH CHO C QUAN QUN L XUT NHP CNH

.....................................................................................................................................
nh mi chp, mt
nhn thng, u
trn, phng nn
trng, c 34 (1)

.....................................................................................................................................
.....................................................................................................................................
Ch thch:
(1) Mi ngi dn mt tm nh, kem theo 3 tm nh ri.
(2) Ghi c th: ngh cp h chiu ln u; cp li h chiu (do mt/ h hng/ ht hn/ tch cp ring h chiu cho
con); cp i
h chiu;iu chnh h v tn, ngy thng nm sinh, s giy CMND trong h chiu; b sung con di 14 tui vo h
chiu ca cha/
m; sa i ni sinh trong h chiu; ngh khc nu c (ghi r l do).
(3) Trng Cng an x, phng, th trn ni thng tr hoc tm tr xc nhn i vi cc 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 c t cch php nhn np h s th Th trng c quan, t chc
xc nhn