Mu DK01

DANH SCH H GIA NH THAM GIA BO HIM Y T

H v tn ch h: V Th Qunh Trm S s h khu (hoc s s tm tr): ..

S in thoi lin h (nu c):
a ch: Thn (Bn, T dn ph): T 150 X (Phng, Th trn): Ho Khnh Nam
Huyn (Qun, Th x, Thnh ph trc thuc tnh): Lin Chiu Tnh (Thnh ph): Nng

Loi i Cha
Mi
tng tham
Ngy, thng, Gii quan h Ghi
STT H v tn S nh danh Ni cp giy khai sinh ln u ang gia
nm sinh tnh vi ch ch
tham gia BHY
h
BHYT T
A B 1 2 3 4 5 6 7 8
1 V Th Qunh Trm DN4480007504588 10/05/1985 N T 150, Ho Khnh Nam, Lin Chiu, Ch h DN
Nng
2

Ghi ch: t nm 2016, hng thng khi c pht sinh tng, gim thnh vin trong h gia nh th ghi b sung danh sch trn theo th t tng ghi trc, gim ghi sau

Ti xin cam oan nhng ni dung k khai l ng s tht v chu hon

ton trch nhim trc php lut
Ngy 14 thng 09 nm 2016
Ch h (hoc ngi i din)
(K, ghi r h tn)

V Th Qunh Trm