U ban nhn dn thnh ph H Ni

CNG HA X HI CH NGHA VIT NAM

c lp - T do - Hnh phc

N NGHCP GIY PHP TIN HNH CNG VIC BC XKnh gi: S Khoa hc v Cng ngh thnh ph Hi Phng1. T chc/c nhn ngh cp giy phpTn giao dch: ..............................................................

a ch tr s : .........................................................................................................................

in thoi:............................. Fax:................................... E.mail: ..Ngi qun l c s: . Gii tnh: Nam/N

Chc v: .....................................................

ngh S Khoa hc v Cng ngh thnh ph Hi Phng cp giy php tin hnh cng vic bc x - s dng (.) thit b X quang chn on y t.

2. Cc cng vic bc x ngh c tin hnh:TTTn cng vic bc xa im tin hnh cng vic bc x

1S dng () thit b X quang chn on thng thng

2S dng 4 () thit b X quang ct lp vi tnh

..

3. Cc h s km theo- .........................- .........................- .........................

( 4 ) cam oan cc khai bo l ng s tht v chp hnh nghim chnh cc quy nh ca php lut v an ton bc x v cc iu kin ghi trong giy php./.., ngy... thng ... nm ....NGI NG U T CHC/C NHN NGH CP GIY PHP(K, ghi r h tn v ng du)

Nu c ngh khai a ch ng k h khu thng tr

Nu c nhn khai bo th khng phi khai mc ny v mc chc v.

Ghi r tng s lng thit b X quang xin s dng v ghi li bng ch trong ngoc n.

Ghi r tng s lng thit b X quang theo tng loi v ghi li bng ch trong ngoc n.

4 Tn t chc ngh cp php hoc Ti nu l c nhn ngh cp php.

BM-CN-03-01 n ngh cp giy php tin hnh cng vic bc x Ngy ban hnh: 30/05/2011

PAGE