M u sô 02/TNĐB
Ban hanh theo Thông tư sô 63/2020/TT-BCA
ngày 19/6/2020
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S :............/BB - VV
C NG HOÀ XÃ H I CH NGHĨA VI T NAM
Đc l p - T do - H nh phúc
BIÊN B N
v vi c hành chính
H i...........gi...........phút,
ngày...........tháng............năm......................................
T i:........................................................................................................................
Chúng tôi g m:
1....................................................C p b c, ch c
v :............................................
Đn v :.............................................................................................................................ơ
2..................................................C p b c, ch c
v :..............................................
Đn v :.............................................................................................................................ơ
Có s ch ng ki n c a Ông/Bà (n u ế ế
có):...............................................................
Sinh ngày:......./......../........Qu c t ch:..............................Ngh
nghi p:..........................
CMND/CCCD ho c h chi u s :................................Ngày ế
c p:....................................
N iơ
c p:...........................................................................................................................
N i ĐKTT ho c n i hi nơ ơ
t i:.......................................................................................
..............................................................................Đi n
tho i:.........................................
Ti n hành l p biên b n v vi c hành chính đi v i:ế
Ông (Bà)/T ch c (Tên t ch c, ng i đi di n theo pháp ườ
lu t):.......................
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Sinh ngày:......../......./...............Qu c t ch:.......................................................................
Ngh nghi p/Lĩnh v c ho t đng ho c Mã s doanh
nghi p:.....................................
N i hi n t i/Đa ch trơ
s :...........................................................................................
CMND ho c CCCD ho c h chi u/GCĐK ho c GP thành l p ế
s : ............................... Ngày c p:.....................N i ơ
c p:......................................................................................
Đi n tho i: ................................... Là:
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N I DUNG V VI C (3)
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(1) Tên c quan c p trên tr c ti p; (2) ơ ế Tên đn v c a ng i có th m quy n l p biên b nơ ườ .(3) Chú ý: N i dung biên b n ph i ghi c th gi ,
ngày, tháng, năm, đa đi m x y ra v vi c ho c v tai n n giao thông; mô t n i dung v vi c ho c v tai n n giao thông. Yêu c u nh ng ng i ườ
có m t cùng ký xác nh n vào t ng trang. Tr ng h p ng i có nghĩa v liên quan, ng i vi ph m hành chính không ký biên b n thì ng i l p ườ ườ ườ ườ
biên b n ph i ghi rõ lý do
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Biên b n l p xong h i ...........gi...........phút cùng ngày, đã đc l i và gi i
thích quy n l i, nghĩa v cho nh ng ng i có tên nêu trên cùng nghe công nh n ườ
đúng và cùng ký tên d i đây./.ướ
NG I CÓ NGHĨA VƯỜ
LIÊN QUAN
(Ký, ghi rõ h tên)
NG I CH NG KI NƯỜ
(Ký, ghi rõ h tên)(n u có) ế
NG I L P BIÊN B NƯỜ
(Ký, ghi rõ h tên)