CNG HA X HI CH NGHA VIT NAM

THNH ON TP. H CH MINHON TNCS H CH MINH

BCH ON TRNG H BCH KHOA

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M phiu: [Tn Chi on]_[MSSV]_2015PHIU THNG TIN ON VIN NM HC 2014 - 2015

I. THNG TIN C NHN

1. H v tn (ch IN HOA):

2. MSSV/MSCB: 3. Chi on:

4. Ngy thng nm sinh: 5. Gii tnh:

6. Dn tc: 7. Tn gio: 8. CMND:

9. Qu qun (x, huyn, tnh/tng ng):

10. H khu thng tr (x, huyn, tnh/tng ng):

11. a ch tm tr:

12. Email: 13. in thoi:

14. Ngi thn (b/ m): 15. in thoi:

II. THNG TIN ON V

14. Ngy vo on: 15. Ni vo on:

16. Tnh trng on tch (nh x vo ( nu c):

(S on vinNu cn, ni lu tr l:

( on khoa

( T bo qun

( Khc: .

(Th on vinNu cn, ni lu tr l:

( on khoa

( T bo qun

( Khc: .

(Ngh quyt kt np on vin

(Ngh quyt ri)Nu cn, ni lu tr l:

( on khoa

( T bo qun

( Khc: .

(Mt ton b on tch

17. Ngy vo Hi Sinh vin Vit Nam:

18. Tham gia lp bi dng nhn thc v ng: ( C ( Khng.

Nu c, ghi r kt qu: nm

19. Ngy vo ng (d b): 20. Ngy vo ng (chnh thc):

21. Chc v ng, on, Hi hin ti:

XC NHN CA CHI ONTP. H Ch Minh, ngy thng nm 2015

TM. CHI ONNgi thc hin

B TH(k v ghi r h tn)

MU 2