MU HK01

(Ban hnh theo Q s 698/2007/Q-BCA(C11) ngy 01 thng 7 nm 2007)

CNG HA 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 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; xm, p, bn, x/ phng/
th trn; qun/ huyn; tnh/ thnh ph. Nu nc
ngoi th ghi tn nc)

NGH NGHIP,
NI LM VIC

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)
SINH NM
Quan
Ngh
CH HIN NAY
TT
H V TN
Na
(6)
h
nghip
N
m

................, ngy ....... thng ....... nm ...........

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