CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc
_______________

BIN BN / BN TNG TRNH TAI NN

Hm nay, vo hi.. ......gi...... ngy.. ... thng...... nm ......

Ti :
Chng ti gm c:
1........... Chc v:
2... Chc v:.
3... Chc v:.
Cng lp bin bn v v tai nn:
Ca ng/B : .
i ch thng tr : .
Ngy xy ra tai nn : .
Ni xy ra tai nn : .
Din bin v tai nn (nu chi tit):

Nguyn nhn v tai nn (nu chi tit)

Hu qu: .

....
Nhng ngi chng kin v tai nn (nu c):
1. Ngi th 1 : .
2. Ngi th 2 : .

Cam oan: Ti/chng ti cam oan nhng k khai trn l ng s thc v hon ton chu
trch nhim v tnh chnh xc ca cc thng tin.

Bin bn/Bn tng trnh c lp xong vo hi:.gi, ngy..thng.nm.ti

XC NHN NGI LP
(Ch k v du ca n v tham gia bo him/c quan ch qun (K, ghi r h, tn)
hoc chnh quyn, cng an ni xy ra tai nn/ngi lm chng)

BM.1C.03.GQKN
19/7/2013