Mu HK01 ban hnh theo

Q s 689/2007/Q-BCA(C11)
Ngy 01-7-2007

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
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 khc (nu c):.....

4. Sinh ngy ././. 5. Ni sinh:....
6. Qu qun: ( 2)

7. Dn tc: 8. Tn gio: 9. CMND s:...........................

10. H chiu s.......................................................11. S h khu s:....................
12. Ni thng tr:............................................
..........................................................................................................................................................

13. Ch hin nay:.............................

...........................................................................................................................................................

14. Trnh hc vn: (3)

..

15. Trnh chuyn mn: ( 4)

..

16. Bit ting dn tc t ngi: 17. Bit ngoi ng:

18. Ngh nghip, chc v, ni lm vic hin nay:..............
..

19. 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 ..

20. Tin n: (Ti danh, hnh pht, theo bn n s, ngy no ca to n)..................

..........................................................................................................................................
..........................................................................................................................................
.......................................................................................................................................
21. 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).

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