ﺔﻴﺒﻌﺸﻟا ﺔﻴﻃاﺮﻘﻤﻳﺪﻟا ﺔﻳﺮﺋاﺰﺠﻟا ﺔﻳرﻮﻬﻤﺠﻟا
ﻲﻤﻠﻌﻟا ﺚﺤﺒﻟا و ﻲﻟﺎﻌﻟا ﻢﻴﻠﻌﺘﻟا ةرازو
طاﻮﻏﻷﺎﺑ ﻲﺠﻴﻠﺛ رﺎﻤﻋ ﺔﻌﻣﺎﺟ
ﺔﻴﻠآ/ﺪﻬﻌﻣ...................................................:..................
ةرﺎﻤﺘﺳا ﺐﻠﻃﺔﻴﻤیدﺎآأ ﺔﻠﻄﻋ
)عدﻮﻳ ﺐﻠﻃﺤﺘﻡا ﺔﻳاﺪﺏ ﻞﺒﻗ ﺔﻴﻤﻳدﺎآﻷا ﺔﻠﻄﻌﻟاﺔﻨﺳ ﻞآ ﻦﻡ لوﻷا ﻲﺳاﺪﺴﻟا تﺎﻧﺎ
)1(
(
ﺔﻴﻠﻜﻝا ﺪﻴﻤﻋ ﺐﺋﺎﻧ ﺪﻴﺴﻝا ﻰﻝإ/ﺪﻬﻌﻤﻝا ﺮیﺪﻣ(*) ﺔﺒﻠﻄﻝﺎﺑ ﺔﻄﺒﺕﺮﻤﻝا ﻞﺋﺎﺴﻤﻝا و تﺎﺳارﺪﻝﺎﺑ ﻒﻠﻜﻤﻝا
ﻊﻗﻮﻤﻟا ﺎﻧأ ،يﺪﻴﺳ ،ﻲﻨﻓﺮﺸﻳ)ة ( ﻩﺎﻧدأ:
ﻢﺳﻻا..................................................................:ﺐﻘﻠﻟا........................:........................................
دﻼﻴﻤﻟا نﺎﻜﻡ و ﺦﻳرﺎﺕ.............../......./.......:ﺔﻳﺪﻠﺏ.........................................:ﺔﻳﻻو...................................:
ﺎﻳرﻮﻟﺎﻜﺒﻟا ﺔﺒﻌﺵ....................................................:ةرود.:ناﻮﺝ..................ﺎﻳرﻮﻟﺎﻜﺒﻟا لﺪﻌﻡ/.......:20.............
ﻞﻴﺠﺴﺘﻟا ﻢﻗر................................: ىﻮﺘﺴﻤﻟا................................:ناﺪﻴﻤﻟا.............................................:
ﺺﺼﺨﺘﻟا و ﺔﺒﻌﺸﻟا.......................................:..................................................................................
ﺔﻴﻌﻡﺎﺠﻟا ﺔﻨﺴﻟا لﻼﺥ ﺔﻴﻤﻳدﺎآأ ﺔﻠﻄﻋ ﻲﺤﻨﻡ ﻢﻜﺕدﺎﻴﺳ ﻦﻡ ﺐﻠﻃأ نأ.......20......./20ﺐﺒﺴﺏ ﻚﻟذ و ،:
ﻦﻣﺰﻣ ضﺮﻣ ﺔﻠیﻮﻃ ةﺪﻤﻝ ضﺮﻣ ﺔﻴﻨﻃﻮﻝا ﺔﻣﺪﺨﻝا
ﺔﻗﺎﻋإ ﺔﻣﻮﻣﻷا ﺔﻴﻠﺋﺎﻋ تﺎﻣاﺰﺘﻝا
ىﺮﺥأ بﺎﺒﺳأ.........................................................................................................................:
ﺔﻴﻟﺎﺘﻟا ﻖﺋﺎﺛﻮﻟا ﻰﻠﻋ يﻮﺘﺤﻳ يﺬﻟا و ﺐﻠﻄﻟﺎﺏ ﻖﻓﺮﻤﻟا ﻒﻠﻤﻟا ﻲﻓ رﺮﺒﻡ ﻮه ﺎﻤآ:
1- .......................................................... 2- ....................................................
3- .......................................................... 4- ....................................................
ﻲﻓ ،طاﻮﻏﻷا......................../......../...........:
ﻡإﻲﻨﻌﻤﻟا ءﺎﻀ.............................................:
ﺦیرﺎﺘﺑ ﺔﻌﻤﺘﺠﻤﻝا ﺔﻨﺠﻠﻝا راﺮﻗ:
.............................................
لﻮﺒﻘﻣ
ﺔﻴﻝﺎﺘﻝا بﺎﺒﺳﻸﻝ ضﻮﻓﺮﻣ:
............................................................................................
................................................................................................................................................
ءﺎﻀﻣإﺔﻨﺠﻠﻝا ﺲﻴﺋر :ﺔﻴﻠﻜﻝا ﺪﻴﻤﻋ ﺐﺋﺎﻧ/ ﺪﻬﻌﻤﻝا ﺮیﺪﻣ(*)
)1( ةدﺎﻤﻟا9 ﻢﻗر راﺮﻘﻟا ﻦﻡ711 ﻲﻓ خرﺆﻤﻟا03 ﺮﺒﻤﻓﻮﻧ2011 :ﺐﻟﺎﻄﻠﻟ ﻲﺳارﺪﻟا رﺎﺴﻤﻟا لﻼﺥ ةﺪﺡاو ةﺮﻡ ﻻإ ﺔﻴﻤﻳدﺎآﻷا ﺔﻠﻄﻌﻟا ﺢﻨﻤﺕ ﻻ.
ةدﺎﻤﻟا10 :ﻲﻟﺎﻌﻟا ﻢﻴﻠﻌﺘﻟا ﺔﺴﺳﺆﻡ ﻪﻨﻴﻌﺕ ﻲﺒﻃ ﺮﻴﺒﺥ يأﺮﻟ ﺐﻟﺎﻄﻟا جﺎﻡدإ ةدﺎﻋإ ﻊﻀﺨﻳ ،ﻲﺒﻃ ﺐﺒﺴﻟ ﺔﻴﻤﻳدﺎآﻷا ﺔﻠﻄﻌﻟا ءﺎﻬﺘﻧا ﺮﺛإ.
(*)ﺔﺒﺳﺎﻨﻡ ﺮﻴﻐﻟا ةرﺎﺒﻌﻟا ﺐﻄﺵأ.
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