BO HIM X HI VIT NAM

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
nh
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T KHAI THAM GIA

Mu s: A01-TS
(Ban hnh km theo Q s: 1111/Q-BHXH
Ngy 25/10/2011 ca BHXH Vit Nam)

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):_______________________, [02]. Gii tnh: Nam N

[03]. Ngy thng nm sinh: __/__/_____, [04]. Dn tc:______, [05]. Quc tch:________
[06]. H khu thng tr hoc tm tr:_________________________________________
[07]. a ch lin h:________________________________________________________
[08]. S in thoi lin h (nu c): c nh: ________________, di ng: ______________
[09]. CMT s:_____________, ngy cp:____/____/_____, ni cp:__________________
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: ____________________________________________
________________________________________________________________________
[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 trn l Sau khi kim tra, i chiu xc nhn cc ni dung k
ng s tht v xin chu hon ton trch nhim trc khai trn l ng v xin chu hon ton trch nhim
php lut.
trc php lut.

.........., ngy____ thng___ nm 201

Ngi khai
(K, ghi r h tn)

H Ni, ngy ___ thng ___ nm201

Th trng n v
(K, ghi r h tn v ng du)

Duyt ca c quan bo him x hi:

Cn b thu
(K, ghi r h tn)

Cn b s, th
(K, ghi r h tn)

Ba nh, ngy___ thng___ nm201

Gim c BHXH
(K, ghi r h tn v ng du)

PH LC: THI GIAN LM VIC C NG BHXH

CHA HNG MT LN
T
thng
nm

n
thng
nm

Din gii

Cn c
ng

T l ng (%)
BHXH BHTN
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