Mu s 03/2013/TT-LLTP

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
T KHAI YU CU CP PHIU L LCH T PHP
(Dng cho c nhn c yu cu cp Phiu l lch t php)
Knh gi: ...................................................................
1. Tn ti l1:.....................................................................................................................
2. Tn gi khc (nu c):............................................................3. Gii tnh :..................
4. Ngy, thng, nm sinh: ........./ .../ ...
5. Ni sinh2:.....................................................................................................................
6. Quc tch:......................................................7. Dn tc:..............................................
8. Ni thng tr 3:..........................................................................................................
.........................................................................................................................................
9. Ni tm tr4:.................................................................................................................
.........................................................................................................................................
10. Giy CMND/H chiu :....................................... 5S:................................................
Cp ngy.......thng.........nm..............Ti:.......................................................................
11. H tn cha:.Ngy/thng/nm sinh
12. H tn m: .Ngy/thng/nm sinh
13.H tn v/chng.. Ngy/thng/nm sinh
11. S in thoi/e-mail:..................................................................................................

QU TRNH C TR CA BN THN
(Tnh t khi 14 tui)
T thng, nm
n thng, nm

Ni thng tr/ Tm tr

Ngh nghip, ni lm vic6

Phn khai v n tch, ni dung b cm m nhim chc v, thnh lp, qun l doanh nghip,
hp tc x (nu c):..........................................................................................................
.........................................................................................................................................
Yu cu cp Phiu l lch t php7: S 1
S 2
Yu cu xc nhn v ni dung cm m nhim chc v, thnh lp, qun l doanh nghip, hp
tc x theo quyt nh tuyn b ph sn (trong trng hp yu cu cp Phiu l lch t php s
1): C
Khng
Mc ch yu cu cp Phiu l lch t php:..
..
S lng Phiu l lch t php yu cu cp:.Phiu.
Ti xin cam oan nhng li khai trn l ng s tht v chu trch nhim v li khai ca mnh.
..........., ngy thng nm
Ngi khai
(K, ghi r h tn )

Ghi ch:
Vit bng ch in hoa, du.
2
Ghi r x/phng, huyn/qun, tnh/ thnh ph trc thuc Trung ng.
3, 4
Trng hp c ni thng tr v ni tm tr th ghi c hai ni.
5
Ghi r l chng minh nhn dn hay h chiu.
6
i vi ngi tng l qun nhn ti ng, cng chc, cng nhn quc phng, qun nhn d b, dn qun t
v th ghi r chc v trong thi gian phc v trong qun i.
7
Phiu l lch t php s 1 l Phiu ghi cc n tch cha c xa v khng ghi cc n tch c xa; thng
tin v cm m nhim chc v, thnh lp, qun l doanh nghip, hp tc x ch ghi vo Phiu l lch t php s
1 khi c nhn, c quan, t chc c yu cu.
Phiu l lch t php s 2 l Phiu ghi y cc n tch, bao gm n tch c xa v n tch cha c
xa v thng tin v cm m nhim chc v, thnh lp, qun l doanh nghip, hp tc x.