‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺠﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﻳﻤﻘﺮﺍﻃﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ‬

‫ﻭﺯﺍﺭﺓ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﻮﻃﻨﻴﺔ‬

‫ﺍﻟﺪﻳﻮﺍﻥ ﺍﻟﻮﻃﻨﻲ ﻟﻼﻣﺘﺤﺎﻧﺎﺕ ﻭﺍﻟﻤﺴﺎﺑﻘﺎﺕ‬
‫ﺍﺳﺘﻤﺎﺭﺓ ﻃﻠﺐ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻹﻟﻜﺘﺮﻭﻧﻴﺔ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ﺩﻭﺭﺓ ‪2011:‬‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪t8912:‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ ‪bacca73:‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ ‪491-0-4420:‬‬
‫‪22-10-2010,8:7:9/1287727629/ver/1287727369‬‬ ‫ﺍﻟﻮﻻﻳــــﺔ‪:‬ﺧﻨﺸﻠﺔ‬
‫ﺍﻟﻤؤﺳﺴــﺔ‪:‬ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ‪-‬ﺧﻨﺸﻠﺔ‬
‫ﺍﻟﺸﻌﺒــــﺔ‪:‬ﺁﺩﺍﺏ ﻭﻓﻠﺴﻔﺔ‬
‫ﺍﻟﻠﻐﺔ ﺍﻟﺜﺎﻟﺜﺔ‪/:‬‬
‫ﺍﻟﻠﻐﺔ ﺍﻷﻣﺎﺯﻳﻐﻴﺔ‪:‬ﻻ ﻟﺴﺖ ﻣﻌﻨﻲ ﺑﺎﻷﻣﺎﺯﻳﻐﻴﺔ‬
‫‪1‬‬ ‫‪4‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪3‬‬ ‫‪3‬‬ ‫‪0‬‬ ‫‪3‬‬
‫ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‪:‬ﻛﻔء‬
‫ﻣﺘﺮﺷﺢ ﻓﻲ ﻗﺴﻢ‪/:‬‬

‫ﺍﻟﻠﻘﺐ ‪:‬ﺑﻦ ﺯﺭﺍﺭﺓ‬

‫ﺍﻻﺳﻢ ‪:‬ﻋﺒﺪ ﺍﻟﻮﻫﺎﺏ‬
‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ ‪-2:‬ﺃﻓﺮﻳﻞ‪1973-‬ﺑـ ‪:‬ﻳﺎﺑﻮﺱﻭﻻﻳﺔ ‪:‬ﺧﻨﺸﻠﺔ‬
‫‪Nom et Prénom: benzerara abdallouahab‬‬ ‫ﺍﻟﺠﻨﺲ ‪:‬ﺫﻛﺮ‬
‫‪Lieu de Naissance : yabous‬‬
‫‪Prénom du Père : mohamed‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ‪:‬ﺟﺰﺍﺋﺮﻳﺔ‬
‫‪Nom et Prénom de la Mère : guebli fatma‬‬
‫‪Tél : 561755989‬‬
‫ﻋﺪﺩ ﺍﻟﺘﺮﺷﺤﺎﺕ ﻓﻲ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ‪:‬ﻟﻠﻤﺮﺓ ﺍﻟﺜﺎﻧﻴﺔ‬
‫‪email : jalilob@gmail.com‬‬ ‫ﻫﻞ ﺳﺒﻖ ﻭﺃﻥ ﺣﺼﻠﺖ ﻋﻠﻰ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ؟‪:‬ﻧﻌﻢ‬
‫‪Adresse : bp 69 touffana 05065-daira :timgad-wilaya :BATNA‬‬

‫ﻗﺮﺍﺭ ﺍﻟﻄﺒﻴﺐ ﻻﺟﺘﻴﺎﺯ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‬

‫ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺃﺩﻧﺎﻩ‪ ....................................................................................................................................................... :‬ﺃﺷﻬﺪ ﺃﻥ ﺍﻟﻤﺘﺮﺷﺢ )ﺓ( ﺍﻟﻤﺬﻛﻮﺭ )ﺓ( ﺇﺳﻤﻪ )ﻫﺎ( ﺃﻋﻼﻩ‪.‬‬
‫)ﺳﺠﻞ ﺍﻟﻌﺒﺎﺭﺓ ﻛﻔء ﺃﻭ ﻏﻴﺮ ﻛﻔء( ﻻﺟﺘﻴﺎﺯ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‬

‫ﺣﺮﺭ ﺑـ‪........................................:‬ﻔﻲ‪..................................:‬‬
‫ﻫﺎﻡ ﺟﺪﺍ‪:‬‬
‫ﺇﻣﻀﺎﺀ ﻭﺧﺘﻢ ﺍﻟﻄﺒﻴﺐ‬ ‫ﺗﻤﻸ ﻫﺬﻩ ﺍﻟﺒﻄﺎﻗﺔ ﺇﺟﺒﺎﺭﻳﺎ ﻣﻦ ﻃﺮﻑ ﻃﺒﻴﺐ ﺍﻟﺼﺤﺔ ﺍﻟﻤﺪﺭﺳﻴﺔ‬
‫ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﺘﻤﺪﺭﺳﻴﻦ ﻭﻃﺒﻴﺐ ﻣﺤﻠﻒ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻸﺣﺮﺍﺭ‪.‬‬

‫ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺍﺳﻔﻠﻪ ﺃﺷﻬﺪ ﺃﻥ ﻫﺬﺍ )ﻩ( ﺍﻟﻤﺘﺮﺷﺢ )ﺓ( )ﺕ( ﻳﺰﺍﻭﻝ ﺩﺭﺍﺳﺘﻪ )ﻫﺎ( ﻓﻲ ﺍﻟﺴﻨﺔ ﺍﻟﺜﺎﻟﺜﺔ ﺛﺎﻧﻮﻱ ﺑﺎﻟﻤؤﺳﺴﺔ ﻭﺃؤﻛﺪ ﺃﻥ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺴﺠﻠﺔ‬
‫ﻋﻠﻰ ﻫﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻗﺪ ﺭﺍﻗﺒﺘﻬﺎ‪.‬‬
‫ﺣﺮﺭ ﺑـ‪........................................:‬ﻔﻲ‪..................................:‬‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬ ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﺘﺮﺷﺢ‪:‬‬

‫‪22-10-2010,8:7:9/1287727629/ver/1287727369‬‬
‫ﻭﺻﻞ ﺍﺳﺘﻼﻡ ‪:‬ﻳﺸﻬﺪ ﻣﺪﻳﺮ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ ﺃﻥ ﺍﻟﺴﻴﺪ)ﺓ(‪.......................................................................‬‬
‫ﻗﺪ ﺳﻠﻢ ﻣﻠﻒ ﺍﻟﺘﺴﺠﻴﻞ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ﺩﻭﺭﺓ‪2011:‬‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪t8912:‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ ‪bacca73:‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ ‪491-0-4420:‬‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ‬ ‫ﺣﺮﺭ ﺑـ ‪................................................ :‬ﻓﻲ‪........................................:‬‬
‫ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬