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MÉu sè 01/LS
phiÕu ®Ò nghÞ
(Hîp ph¸p ho¸ hoÆc chøng nhËn l·nh sù)
letter of request
For consular legalization/certification
KÝnh göi: côc l·nh sù – bé ngo¹i giao
To : consular department – mofa
1. Hä vµ tªn ngêi nép hå
s¬: .............................................................................................
Applicant’s name
CMND/Hé chiÕu sè:.........................Ngµy cÊp:......................N¬i
cÊp:.................................
ID/Passport No. Date of issuance Place of
issuance
§iÖn tho¹i
sè:...................................................................................................................
Telephone No.
2. §Þa chØ ngêi nép hå
s¬:..................................................................................................
Address
3. V¨n b¶n ®Ò nghÞ hîp ph¸p ho¸ hoÆc chøng nhËn l·nh sù gåm:
Document(s) requesting for consular legalization/certification
1) ..................................................................................................................
2) ..................................................................................................................
3) ..................................................................................................................
4) ..................................................................................................................
5) ..................................................................................................................
Tæng céng :.............................v¨n b¶n
Total document(s)
5. V¨n b¶n trªn sÏ sö dông t¹i n-
íc........................................................................................
Document(s) will be applicable in
6. Môc ®Ých sö
dông : ..............................................................................................................
For the purpose of
T«i xin cam ®oan nh÷ng lêi khai trªn lµ ®óng sù thËt vµ hoµn toµn chÞu tr¸ch
nhiÖm tríc ph¸p luËt vÒ tÝnh x¸c thùc cña hå s¬ trªn.
I hereby certify that the information provided above is true and
correct in all details. I am fully liable for the authenticity of the above-
mentioned documents.
Hµ Néi, ngµy.............th¸ng...........n¨m 200.....
Date Month Year
Ngêi nép ®¬n
(Ký vµ ghi râ hä tªn)
Applicant’s signature
L u ý (notice) :
- §Ýnh kÌm 01 b¶n photocopy hå s¬, CMND/hé chiÕu ®Ó lu t¹i Côc L·nh sù.
Please attach a copy of your ID/passport and document(s) for office record
- Ngêi nép thay ph¶i cã giÊy uû quyÒn cã x¸c nhËn cña c¬ quan thÈm quyÒn (Phßng C«ng chøng,
UBND, c¬ quan §¹i diÖn VN t¹i níc ngoµi).
In case of powers authorized, a certified Power of Attoney is requied
- NÕu ngêi nép thay lµ bè, mÑ, anh chÞ em ruét, vî (chång) th× kh«ng cÇn giÊy uû quyÒn, nhng
ph¶i xuÊt tr×nh giÊy tê chøng minh quan hÖ (giÊy khai sinh/hé khÈu/kÕt h«n/ giÊy chøng nhËn cña
UBND phêng/x·).