CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

Mu HK01 ban hnh theo Q

s 689/2007/Q-BCA(C11)
Ngy 01-07-2007

BN KHAI NHN KHU

(Dng cho ngi t 14 tui tr ln)
1. H v tn khai sinh: (1) .2. Gii tnh:..
3. H v tn gi khc (nu c):..
4. Sinh ngy ././. 5. Ni sinh:..
6. Qu qun: ( 2 ) ...
7. Dn tc: 8. Tn gio: 9. CMND/ H chiu s....
10. Ni thng tr: ....

11. Ch hin nay: ...

12. Trnh hc vn: ( 3) .. 13. Trnh chuyn mn: ( 4 ) .

14. Bit ting dn tc t ngi: 15. Bit ngoi ng:..
16. Ngh nghip, chc v, ni lm vic hin nay: ....................
..
17. T 14 tui tr ln n nay u, lm g:
T THNG, NM
N THNG,
NM

CH
(ghi r s nh, ng ph; t, xm, p, bn, x/
phng/ th trn; qun/ huyn; tnh/thnh ph.
Nu nc ngoi th ghi r tn nc)

NGH NGHIP, NI LM VIC

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(1) Vit ch in hoa du. (2) Ghi theo giy khai sinh hoc qu gc (3) Ghi trnh hc vn cao nht. Tin s, Thc s, i
hc, Cao ng, Trung cp, Trnh ph thng (12/12, 7/10..). (4) Ghi r trnh chuyn mn cao nht: Tin s Y hc, Thc
s qun l gio dc, c nhn lut ..

18. Tin n
B BT NGY

TI DANH, N PHT

19. Quan h gia nh: (B, m; anh, ch, em rut; v/ chng, con) ( 5)

TT

H V TN

SINH NM
Nam

QUAN
H

NGH
NGHIP

CH HIN NAY

..., ngy thng .. nm .

NGI KHAI HOC NGI VIT H
(Cam oan; k ghi r h tn)

(5) Ghi c cha, m;con nui; ngi nui dng; ngi gim h theo quy nh ca php lut(nu c).

(6) S nh, ng ph; t, xm, p, bn, x/ phng/ th trn; qun/ huyn; tnh/thnh ph. Nu nc ngoi th ghi r tn
nc
(Mu ny c th in ra s dng)