TNG LIN ON LAO NG VIT NAM CNG HA X HI CH NGHA VIT NAM

TRNG I HC TN C THNG c lp - T do - Hnh phc

----------------- ---------------

nh 3 x 4
BN T KHAI L LCH

- H tn Sinh vin (ch in hoa): Lp :. Kha:..........

- Ngy thng nm sinh : .Ni sinh :...... M s sinh vin:.
- Dn tc : Tn gio : .................................. Nam ( n ) : ...
- H khu thng tr (s nh) ng( p) : Phng
(x ):.Qun ( huyn ) : ......................................
Tnh ( Thnh ph ) ...... in thoi:...............................................................
a ch lin lc ( Tm tr ) : .............................................................................................................
.............................................................................................................. in thoi:.....................................
- i tng bn thn ( HSPT, CB- CNV ):..
- Ngh nghip ( nu c ) :Ni cng tc :..................in thoi:..
- Tt nghip PTTH kha ngy :..........Bng tt nghip ( THPT, THBT , THCN ):..
- Ngy vo on : Ngy vo ng : ..............................
- Chc v cn b on cao nht :................................................................................................................
- Chc v cn b lp cao nht :...................................................................................................................
- Nng khiu : ..Din chnh sch ( nu c ):........................
- H tn cha:................ Tui : ..........
- Ngh nghip : Ni cng tc :.....................................
- H tn m :............................................................Tui :...
- Ngh nghip : .Ni cng tc :........................
- H tn v & chng :.............Tui :....
- Ngh nghip :Ni cng tc :..............................
Ti cam oan nhng li khai trn l ng s tht . Nu c g sai tri ti xin hon ton chu trch
nhim . Ngy .thng nm 2009
Xc nhn ca chnh quyn phng (x) Sinh vin k tn
hoc C quan ang cng tc. (Ghi r h tn)

Ch : Tt c cc loi giy t c dn nh , phi c chnh quyn a phng hoc c quan ng du gip lai ln nh.