‘Miu CCO1 ban hinh kém theo “Thong tu 95 66/2015/TT-BCA ngay 15/12/2015 CONG HOA XA HOI CHU NGHIA VIET NAM Doc lip - Ty do - Hanh phic TO KHAI CAN CUGC CONG DAN 1. Ho, chit dém va tén(1):.... 2. Ho, chil dom va ton g0i khde (néa 06): cee cesses cocsceseeseeeess 3. Ngay, thing, nim sinh... Lecceccecceoseees 34 Gi6i tinh (Nanvnid):.. cesses 5. S6 CMNDICCCD (2): 6. Dan toc: : 8, Quéc tich:. 9. Tinh trang h6n nha... 10, Nhém méu (néu 06): LL. Noi ding ky Khai sinh... 0cccccsescesessrneeeeereeeeeeoee . 12. Qué quén: 13. Noi thutng tr: . 7. Ton gio: 14. Noi 6 hign t 15, Nene nghigp:.. 17. Ho, chit dém va tén eta cha ():. 86 CCCDICMND(*): 18. Ho, chit dém va tén cba me (1): ees sescosssssss se Qué tich: 86 CCCD/CMND(*): 19. Ho, chit dém va tén cba vg (ching) (: essen Qui tich: $6 CCCDICMND(*): 20. Ho, chit dém va tén cia ngudi DHPC): eceeceeees Quéc tich; S86 CCCD/CMND(*): 21. Ho, chil dém va tén cita chi hO(: .. S88 CCCD/CMND&): Quan hé VOi Chi HO: eeeeeeeeeeeeeeeee 22. Yeu edu cita cong dan: - Cap, ai, cfip lgi thé Can eutée cOng dan: - Xe nh§n s6 Chttng minh nhan dan (c6/khdng): . : - Chuyén phat bing duéng Buu dién dén tn tay cong dan (conkndng): Dia chi nhiin:, coven . S6 dign thoai: Tai xin cam doan nhitng thong tr tin ké kha ren a ng st that. angary........thdng.......néim. NGUOI KHAI (KY, ghi r0 ho tén) Quéc tich:KET QUA XAC MIN D6i Tang thu cin cutéc cng dn - Phong Canh sat QLHC vé TTXH tra di két qua d6i chiéu, xéc minh v6i hd s6 géc (c6 hoiie khong c6 hé s6 ge, néu c6 hé so g6c thi c6 ndi dung gi khiéc voi t8 khai CCD hoie Phiéu thu nhfin thong tin CCCD kém theo?) s ngay. théng.......netm. Cén bé tra cia vce ceeeeeeeeeeeeee we (KY, ghi r6 ho ten) Ghichti: (1): Ghi ch@inhoa di dé -(2): Ghisé CMND/CCCD daa dude edip lin gdn nhdi (néiu la CMND 06 9.86 thi 3 6 cub gach chéo). -(3): Doi trudng Doi Tang thucéin cudc cong din Phong Canh sdt QLHC ve TTXH. -(*): Khing bas bube cong dan phdi ke khai. = CCCD a viét tt cia Cain cudc cong dan; CMND la viét td ciia Ching minh nhan dan; BDHP la viet tat cila dai dién hop phdp