TÊN C QUANƠ C NG HÒA XÃ H I CH NGHĨA VI T NAMỘ Ộ Ủ Ệ
………………... Đc l p – T do – H nh phúcộ ậ ự ạ
S : ……/CVố --------------
V/v ……………
Kính g i: ử………………
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N i nh n:ơ ậ TH TR NG C QUANỦ ƯỞ Ơ
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