ãáÍÞ ( 1)
äãæÐÌ ÈíÇäÇÊ ÇáãÕÏÑíä
ÇáÇÓã ÇáÞÇäæäì ááÔÑßÉ
ÚäæÇä ÇáÝÑÚ ÇáÑÆíÓì
ÑÞã ÇáÊáíÝæä
ÑÞã ÇáÝÇßÓ
ÇÓã ææÙíÝÉ ÇáÔÎÕ ÇáãÓÆæá Úä ÇáÇÊÕÇá ÈÔÑßÉ ãÕÑ ááãÞÇÕÉ
ÇáßíÇä ÇáÞÇäæäì ááãÔÊÑß ÇáãÝæÖ (Åä æÌÏ)
ßæÏ ÇáãÔÊÑß ÇáãÝæÖ ( Åä æÌÏ)
ÇÄßÏ ÕÍÉ åÐå ÇáãÚáæãÇÊ Ýì ÊÇÑíÎ ........... æÇÞÑ ÈÇÈáÇÛ ÔÑßÉ ãÕÑ ááãÞÇÕÉ Ýì ÍÇáÉ ÍÏæË Çì ÊÛíÑ .
ÎÊã ÇáÔÑßÉ ÇáãÕÏÑÉ ÊæÞíÚ ÑÆíÓ ãÌáÓ ÇáÇÏÇÑÉ Ãæ ÇáÝæÖ Úäå
ãáÍÞ ( 2)
äãæÐÌ ÇáØáÈ ÇáãÞÏã ãä ÞÈá ÇáÔÑßÉ ÇáãÕÏÑÉ ááÍÕæá Úáì ßÔÝ ÈÃÓãÇÁ ÇáãÓÇåãíä
ÈíÇä íÑÓá ãä ÇáÔÑßÉ ÇáãÕÏÑÉ ( Ãæ ÇáãÝæÖ ÚäåÇ) Çáì ÞÓã ÇáãÚáæãÇÊ ÈÔÑßÉ ãÕÑ ááãÞÇÕÉ .
ÇáÃæÑÇÞ ÇáãÇáíÉ ÇáãÚäíÉ ( ßæÏ ÔÑßÉ ãÕÑ ááãÞÇÕÉ ) : ...............................................
ÇáÃÓã :................................................. ...............................................
ÊÇÑíÎ ÇáÊÍÞÞ :................................................. .......................................
äæÚ ÇáØáÈ :
1 ÌãíÚ ÇáãÓÇåãíä
2 ãÓÇåãíä íãáßæä ............... Óåã
ÃÓáæÈ ÊÑÊíÈ ßÔÝ ÇáãÓÇåãíä : ..............
( ÅÎÊÇÑ æÇÍÏÉ ÝÞØ ) 1 = ÈÇáßãíÉ ( ÇáÃßËÑ Ëã ÇáÃÞá )
2 = ÈÇáÃÓãÇÁ
3 = ÇÎÊíÇÑÇÊ ÃÎÑì : .................
ØÑíÞÉ ÊÓáíã ÇáãÚáæãÇÊ:
1 = Úáì ÕæÑÉ ÞæÇÆã æÑÞíÉ
2 = ÏíÓß ßãÈíæÊÑ
ÇáÔÎÕ ÇáãÓÆæá ãä ÇáÔÑßÉ ÇáãÕÏÑÉ ÃãÇã ÔÑßÉ ãÕÑ ááãÞÇÕÉ :
ÇáÃÓã : .................................................. ...........................................
ÇáæÙíÝÉ :. .................................................. ..........................................
ÇáÚäæÇä :................................................. ................................
ÇáÊáíÝæä :..................................
ãÚáæãÇÊ ÃÎÑì :
• ÇáÃÓã ÇáËáÇËì Ãæ ÇáßíÇä ÇáÞÇäæäì ááãÓÇåãíä .
• ÚäÇæíä ÇáãÓÇåãíä
• ßãíÉ ÇáÃÓåã
( ãáÍÞ 3)
ÎØÇÈ ÊÝæíÖ
( Èíä ßá ãä )
1. ÔÑßÉ : .................................................. ................
2. ÑÃÓãÇá : .................................................. ... Ìäíå ãÕÑì
3. æÚäæÇäåÇ : .................................................. ................
4. ÓÌá ÊÌÇÑì ÑÞã : .................................................. ................
æ íãËá ÇáÔÑßÉ ÇáÃÓÊÇÐ / ÇáÓíÏÉ : .................................................. ................
( æíÔÇÑ ÇáíåÇ ÈÚÏ Ðáß ÈÇáãÕÏÑ )
ÊÝÜÜÜÜÜæÖ
1. ÔÑßÉ :................................................. ..................
2. ÑÃÓãÇá :................................................. ..... Ìäíå ãÕÑì
3. æÚäæÇäåÇ : .................................................. ................
4. ÓÌá ÊÌÇÑì ÑÞã : .................................................. ................
æ íãËá ÇáÔÑßÉ ÇáÃÓÊÇÐ / ÇáÓíÏÉ : .................................................. ................
( æíÔÇÑ ÇáíåÇ ÈÚÏ Ðáß ÈÇáãÝæÖ )
Êã ÇáÃÊÝÇÞ ãÚ ÇáãÝæÖ ÇáÓÇÈÞ ÐßÑå Úáì ÇáÞíÇã ÈÌãíÚ ÇÌÑÇÁÇÊ ÞíÏ ÇáÔÑßÉ ÇáãÕÏÑÉ Ýì äÙÇã ÇáÍÝÙ ÇáãÑßÒì äíÇÈÉ Úä ÇáÔÑßÉ ÇáãÕÏÑÉ ááÅÕÏÇÑÇÊ ÇáÊÇáíÉ :
• .................................................
• .................................................
• .................................................
• .................................................
È ) ÈÇáäÓÈÉ áåÐå ÇáÅÕÏÇÑÇÊ ÇáÊì Êã ÇáÊÝæíÖ ÈÔÃäåÇ ÓæÝ íßæä ÇáãÝæÖ åæ ÇáãÊÍÏË ÇáÑÓãì
ÃãÇã ÔÑßÉ ãÕÑ ááãÞÇÕÉ æÇáÊÓæíÉ æÇáÍÝÙ ÇáãÑßÒì .
ÇáãÝæÖ ÓæÝ íÞÏã ÊÞÇÑíÑ ÏæÑíÉ ááÔÑßÉ ÇáãÕÏÑÉ ÈÇáØÑÞ ÇáÃÊíÉ:
• .................................................
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Ì) ÇáÔÑæØ ÇáãÇáíÉ áåÐÇ ÇáÊÝæíÖ :
• .................................................
• .................................................
æåÐÇ ÇáÃÊÝÇÞ ÇáÐì íÊã Èíä ÇáÔÑßÉ ÇáãÕÏÑÉ æ ÇáãÝæÖ ÚäåÇ íßæä ÓÇÑíÇ ÎáÇá ÇáÝÊÑÉ
• ãä --/--/---
• Çáì --/--/--- ( ÞÇÈáÉ ááÊÌÏíÏ ÈäÇÁÇð Úáì ÃÊÝÇÞ ÇáØÑÝíä)
- ÊÍÑíÑÇ Ýì --/--/---
ÇáÊæÞíÚ ( ØÑÝ Ãæá ) ÇáÊæÞíÚ ( ØÑÝ ËÇäì)
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