c lp - T do - Hnh phc Mu s: A01-TS (Ban hnh km theo Q s: 1111/Q-BHXH Ngy 25/10/2011 ca BHXH Vit Nam)
T KHAI THAM GIA
nh 3x4
BO HIM X HI, BO HIM Y T
M s: __________________________
I. THNG TIN CA NGI THAM GIA:
[01]. H v tn (vit ch in hoa):_NGUYN NH HU , [02]. Gii tnh: Nam
N [03]. Ngy thng nm sinh: 19/09/1988 , [04]. Dn tc: Kinh, [05]. Quc tch: Vit Nam [06]. H khu thng tr hoc tm tr:_Lc Hng, Vn Lm, Hng Yn______________ [07]. a ch lin h:_ Trn Thi Tng, Cu Giy, H Ni__________________________ [08]. S in thoi lin h (nu c): c nh: ________________, di ng: _097 5678 038_____ [09]. CMT s:145240041_______, ngy cp:_31/07/2003____, ni cp:_Cng an Hng Yn_ II. THAM GIA BO HIM X HI BT BUC, BO HIM Y T:
[10]. Quyt nh tuyn dng, hp ng lao ng (hoc HLV): s___________________
ngy ___/___/_____ c hiu lc t ngy ___/___/_____ loi hp ng _______________ [11]. Tn c quan, n v, a ch: __Cng ty C phn nh Sng Xanh_____________ ________________________________________________________________________ [12]. Ni lm vic:_________________________________________________________ [13]. Chc v, chc danh ngh, cng vic: ______________________________________ ________________________________________________________________________ [14]. Lng chnh: ___________________________, [15]. Ph cp: [15.1]. PCCV___, [15.2]. TNN____, [15.3]. TNVK____, [15.4]. Khc ____ [16]. M s s bo him x hi c cp (nu c):_______________________________ [17]. M s th bo him y t c cp (nu c):________________________________ [18]. Ni ng k khm cha bnh ban u (theo hng dn ca c quan BHXH): ____________ ________________________________________________________________________ [19]. Quyn li hng bo him y t (nu c):_____________________________________ Xc nhn ca ngi s dng lao ng Ti xin cam oan nhng ni dung k khai Sau khi kim tra, i chiu xc nhn cc ni trn l ng s tht v xin chu hon ton dung k khai trn l ng v xin chu hon trch nhim trc php lut. ton trch nhim trc php lut. .........., ngy ....... thng ....... nm ........... .........., ngy ....... thng ....... nm ........... Ngi khai Th trng n v (K, ghi r h tn) (K, ghi r h tn v ng du) Duyt ca c quan bo him x hi: Cn b thu (K, ghi r h tn)