CNG HA X HI CH NGHA VIT NAM

c lp T do Hnh phc
--------- oOo --------......., ngy

thng

nm 201

N XIN XC NHN CNG TC

H tn (ghi ch in hoa): ..............................................................................................................
a ch thng tr: ......................................................................................................................
a ch tm tr: ............................................................................................................................
S CMND:........................Ngy cp:........................................... Ni cp:................................
S in thoi nh:............................. ............................S TD: ............................................
Hin ang lm vic ti:................................................................................................................
Chc danh/chc v:.....................................................................................................................
a ch c quan: ...........................................................................................................................
in thoi lin lc: ......................................................................................................................
Ngy vo lm vic:......................................................................................................................
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L do xc nhn cng tc:............................................................................................................
.....................................................................................................................................................
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Ti xin cam oan nhng li khai trn l ng s tht, nu c g sai tri ti xin chu mi trch
nhim trc php lut.
Knh trnh th trng c quan xem xt v xc nhn.
XC NHN CA C QUAN

NGI KHAI
(K v ghi r h tn)