Mu 1a/XNTA (C27)

CNG HO X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
---------------------------N NGH XC NHN TNH TRNG TIN N

Knh gi:(1) ...............................................................................................................

..
Tn ti l ........................................................................................Nam/n..................
Tn gi khc:.............................................................................................................................
Sinh ngy........./......../................, ti..........................................................................................
Nguyn qun:.............................................................................................................................
Ni ng k NKTT: ..................................................................................................................
Ch hin nay:..........................................................................................................................
Ngh nghip, ni lm vic:........................................................................................................
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CMND/h chiu s:......................cp ngy ......./......./........ , ti..............................................
PHN KHAI V CHA, M:
CHA
H tn:...........................................................
Sinh ngy.........thng.........nm......................
Nguyn qun:................................................
Ni ng k NKTT:......................................
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Ch hin nay:.............................................
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M
H tn:.........................................................
Sinh ngy.........thng.........nm...................
Nguyn qun:..............................................
Ni ng k NKTT:....................................
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Ch hin nay:...........................................
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PHN KHAI V QU TRNH C TR TI VIT NAM CA BN THN:

(T khi 14 tui tr ln)

T thng, nm
n thng, nm

C TR TI
(Ghi r thn, x, huyn, tnh hoc s nh, t dn ph, phng/th trn, qun/th
x...)

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2
T thng, nm
n thng, nm

C TR TI
(Ghi r thn, x, huyn, tnh hoc s nh, t dn ph, phng/th trn, qun/th
x...)

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Ti cam oan s lc l lch khai trn l ng, ngh (1) ........................................

cp cho ti giy xc nhn khng tin n xin i lm vic c thi hn i Loan./.
................ngy.......thng.......nm........
NGI LM N
(K v ghi r h tn)

(1) Phng H s Cng an tnh/TP hoc Cc H s nghip v cnh st - B Cng an