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:
Noi c6ng t{c
(ho[c noi
thuong

tu)

(ghi rO d6i vOi.turng d6ng trlc gi6,
n6u c6)

Le tAc gia l"hOm

;;;;; ilili*;;ffi ;; ;il k#;;E;; ii# il;#;i,,;6;a
r;iJ;;';;a*ffi; i;i6;;' "
da;tu te

ilE$1

Chric
danh

Trinh

iIQ

chuy6n
m6n

NQi dung c6ng
viQc h6 trg

TOi
lol (chung t6i) xin
xi cam
toan chlu tu6ch nhipm trudc ph6p luflt.

....., ngdy... thdng... ndm ..,..

Ngudi nQp tlon

(Klvd ghi rd he ftn)