PHU LUC I rr.lAu ooN yEu cAu bONaNr{AN sAwc rrcN
(Ban hdnh kim theo e,ry? dinh sij 3 O tzotilgo_iBwb ngffi/ro /2014
cila (Iy ban nhdn ddn tinh Fao Airtl
coNG HOA XA nQl cn0 NCuIa vrrDT NAM
DOc I0p - Trf do - Hanh phric DOn yEu cAu coNG MrAN sANc KrrtN Kfnh gti:
Le tAc gia l"hOm
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- Nhfrng th6ng tin c6n a"dbeo;a;i;#i;
ril.aiilkie,;a" ihtila ;; dG;;; kt6;;'''
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;6'.H.::?'tr^i1ffi ff';nl.l*r,e;"#t'H$1f,._txrum;t{t"egi}il3n"ria
Danh s51.as6ch nh dd tham eia 6o duns thrl ktilu"il;i;ffii
TT
Hg vi
tGn
Ngny thdng n5m sinh
Noi c6ng tfc
(ho[c noi
thu0mg tru)
Chric danh
Trinh iIQ chuy6n m6n
NQi dung c6ng
viQc h6 trg
lol t6i) xi
TOi (chung t6i) xin cam
toan chlu tu6ch nhipm trudc ph6p luflt
, ngdy thdng ndm ,
Ngudi nQp tlon (Klvd ghi rd he ftn)
Noi c6ng t{c (ho[c noi thuong tu) (ghi rO d6i vOi.turng d6ng trlc gi6,
n6u c6)