SOCIALIST REPUBLIC OF VIETNAM

Independence- Freedom- Happiness

NOTICE OF HOUSEHOLD CHANGE

1.     Full name: …………………………………………………….
2.     Sex: ……………………………………………………………
3.     Dossier No.:…………………………………………………….
4.     Other names:………………………………………………….
5.     Date of birth: …………………………………………………
6.     ID No.: ………………………………………………………..
7.     Native place:……………………………………………………
8.     Ethnic: …………………………………. ……………………..
9.     Religion: ………………………………………………………
10. Occupation, place of work: …………………………………….
11. Place of permanent residence: ………………………………..
12. Place of move-in: ……………………………………………….
13. Householder’s full name: ………………………………………..
14. Content of the change: ………………………………………….
15. Companions in the household: …………………………………..

Se. No	Full name	Date of birth	Place of birth	Native place	Ethnic	Religion	Job	ID card	Relation with the householder
1	2	3	4	5	6	7	8	9	10

Confirmation of the Public Security
(Commune/Precinct/Town of former household registration)

Comment of householder
(Sign and clear full name)
Agreed.
(Signed)
Truong Thu Huong

April 1^st, 2006
Declarant
(Sign and clear full name)
(Signed)
Pham Duy Nghia

PHIẾU BÁO THAY ĐỔI NHÂN KHẨU

Independence- Freedom- Happiness

NOTICE OF HOUSEHOLD CHANGE

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