…………..………………..……………
………………..………………….…….
………………..………………….…….( 1 )
C NG HOÀ XÃ H I CH NGHĨA VI T NAMỘ Ộ Ủ Ệ
Đc l p - T do - H nh phúcộ ậ ự ạ
S : ố(2) /TLGCLH ………, ngày…...…tháng ......... năm ............
TRICH LUC GHI CHÚ LY HÔN
H , ch đm, tênọ ữ ệ : ............................................................................................................................................................................................
Ngày, tháng, năm sinh: .....................................................................................................................................................................................
Gi i tính: ớ…………........……. Dân t c: ộ.............................................Qu c t ch: ố ị .......................................................................................
Gi y t tùy thân: ấ ờ ...................................................................................................................................................................................................
................................................................................................................................................................................................................................................
N i c trú: ơ ư ..................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
Đc ghi vào s h t ch vi c ượ ổ ộ ị ệ (3).....................................................đã gi i quy t t i n c ngoài v iả ế ạ ướ ớ
ng i có tên d i đây: ườ ướ
H , ch đm, tênọ ữ ệ : ............................................................................................................................................................................................
(4)Ngày, tháng, năm sinh: ................................................................................................................................................................................
Gi i tính: ớ…………........……. Dân t c: ộ……………....................…Qu c t ch: ố ị ......................................................................................
Gi y t tùy thân: ấ ờ
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
N i c trú: ơ ư ..................................................................................................................................................................................................................
................................................................................................................................................................................................................................................
Theo:(5).............................................................................................................................................................................................................................
.............................................. s doố
................................................................................................................................................................................................................................................
....................................................................c p ngàyấ............................................................................................................................................../.
NG I KÝƯỜ TRÍCH L CỤ
(Ký, ghi rõ h , ch đm, tên, ch c v , đóng d u)ọ ữ ệ ứ ụ ấ
1
2
3
4
