CHNG TRNH HC BNG PVEP NGI I TM LA

H S NGH XT CP

Dn
nh
3x4

HC BNG HC SINH NGHO VT KH

Knh gi: BAN IU HNH CHNG TRNH HC BNG

H v tn: ........................................................... Ngy sinh: ................... Dn tc: ................

H khu thng tr: ...............................................................................................................
a ch lin lc: ........................................................................................................................
S in thoi lin h (bt buc c): ........................................... Email: .....................................
Sinh vin trng i hc: .................................. Chuyn ngnh: ........................................
Thnh tch hc tp (im thi i hc im trung bnh nm): ....................................................
....................................................................................................................................................
Thnh tch trong cuc sng (c bng khen ca trng,, tnh thnh, b ngnh...):
....................................................................................................................................................
Tnh trng sc kho (bnh bm sinh, khuyt tt, tai nn):
....................................................................................................................................................
Hon cnh gia nh:
1. Thu nhp ca ton gia nh/ 1 nm: ......................................................................................
2. Quan h gia nh (ng b, b m, anh ch em, nhng ngi ang chung sng):
Tn thnh vin

Quan h

Ngh nghip

Thu nhp/

Ghi ch

1 nm
1.
2.
3.
4.
5.
6.

Tr s: 12 H Xun Hng Hai B Trng H Ni

in thoi: 04-39437750, Fax: 04-39431358 Email: ttnd@gmail.com

Quy ch hot ng ca Chng trnh hc bng PVEP Ngi i tm la

3. Trnh by gia cnh:

...................................................................................................................................................
........................................................................................................................................................
4. C s vt cht (trnh by tnh trng nh ca, ti sn, rung vn):
- Nh ca (nh cp 4/ nh tranh/ mi bng):
..................................................................................
- Ti sn ( c, vt dng: tivi, xe my, xe p):
............................................................................
- Rung vn (c bao nhiu din tch rung vn, t tt/xu?):
.........................................................
5. Gia nh c ngnh ngh/cng vic khc ngoi lm rung, chn nui:
Ngh g? Thu nhp bao nhiu/ 1 thng?

Khng

........................................................................................................................................................
6. c cp s h ngho:

Khng

C - Thi hn cp: ...............................................

7. Gia nh chnh sch:

Khng

C - Gii thch r: ...............................................

Nguyn vng sau khi tt nghip i hc (C cam kt c th tng trng hp khi cn)
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Ti xin cam kt nhng iu khai trn l hon ton ng s tht. Ti xin chu trch nhim trc Ban
iu hnh Chng trnh hc bng PVEP Ngi i tm la v nhng thng tin trn.
Trn trng knh cho!
Ngy ..... thng ..... nm .....
(K tn)
Xc nhn ca a phng v hon cnh gia nh
(K tn, ng du)

H v tn: .............................

Xc nhn ca Ban gim hiu nh trng v thnh tch hc tp

(K tn, ng du)

Tr s: 12 H Xun Hng Hai B Trng H Ni

in thoi: 04-39437750, Fax: 04-39431358 Email: ttnd@gmail.com

Quy ch hot ng ca Chng trnh hc bng PVEP Ngi i tm la

CHNG TRNH HC BNG PVEP NGI I TM LA

H S NGH TI TR KINH PH

Dn nh
3x4

TI NGHIN CU KHOA HC
Knh gi: BAN IU HNH CHNG TRNH HC BNG

H v tn: ............................................................. Ngy sinh: ................... Dn tc: .......

H khu thng tr: .........................................................................................................
a ch lin lc: ................................................................................................................
S in thoi lin h (bt buc c): ........................................... Email: .....................................
Sinh vin trng i hc: (Ghi r nm hc th, chuyn ngnh...) ....................................................

Thnh tch trong hc tp (im trung bnh nm hc):

............................................................................................................................................
ti nghin cu khoa hc v ng dng (Ghi r cp, ngnh cng nhn):
......................................................................................................................................
Tnh trng sc kho (bnh bm sinh, khuyt tt, tai nn):
....................................................................................................................................................
Nguyn vng sau khi tt nghip i hc
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Ti xin cam kt nhng iu khai trn l hon ton ng s tht. Ti xin chu trch nhim trc Ban
iu hnh Chng trnh hc bng PVEP Ngi i tm la v nhng thng tin trn.
Trn trng knh cho!
Ngy ..... thng ..... nm .....
(K tn)
Xc nhn ca Ban Gim hiu Nh trng
(K tn, ng du)

H v tn: ...................

Tr s: 12 H Xun Hng Hai B Trng H Ni

in thoi: 04-39437750, Fax: 04-39431358 Email: ttnd@gmail.com

Quy ch hot ng ca Chng trnh hc bng PVEP Ngi i tm la

CHNG TRNH HC BNG PVEP NGI I TM LA

H S NGH XT CP HC BNG SINH VIN TI NNG

Dn nh
3x4

Knh gi: BAN IU HNH CHNG TRNH HC BNG

H v tn: ........................................................... Ngy sinh: ................... Dn tc: ................

H khu thng tr: ...............................................................................................................
a ch lin lc: ........................................................................................................................
S in thoi lin h (bt buc c): ........................................... Email: .....................................
Sinh vin trng i hc: .................................. Chuyn ngnh: ........................................
Thnh tch hc tp (im thi i hc im trung bnh hc k/ nm):
....................................................................................................................................................
Thnh tch trong cuc sng (c bng khen ca trng,, tnh thnh, b ngnh...):
....................................................................................................................................................
Nguyn vng sau khi tt nghip i hc (C cam kt c th tng trng hp khi cn)
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Ti xin cam kt nhng iu khai trn l hon ton ng s tht. Ti xin chu trch nhim trc Ban
iu hnh Chng trnh hc bng PVEP Ngi i tm la v nhng thng tin trn.
Trn trng knh cho!
Ngy ..... thng ..... nm .....
Xc nhn ca Ban gim hiu nh trng

(K tn)

(K tn, ng du)

H v tn: .....................................

Tr s: 12 H Xun Hng Hai B Trng H Ni

in thoi: 04-39437750, Fax: 04-39431358 Email: ttnd@gmail.com