‫ﺍﻟﺠﻤﻬﻮﺭﻳـﺔ ﺍﻟﺘﻮﻧﺴﻴـﺔ‬

‫ﻭﺯﺍﺭﺓ ﺍﻟﻤﺎﻟﻴـــﺔ‬

‫اﻹدارة اﻟﻌﺎﻣﺔ ﻟﻠـﻤﺮاﻗﺒﺔ اﻟﺠﺒﺎﺋﻴﺔ‬

‫ﺟــــﺪول إﺣــــﺎ ﻟﺔ ﻋ ﻠﻰ ﺣﺎﻣــﻞ ﻣﻤــــــ ﻐــ ﻨــﻂ‬

‫ﺗﺼﺮﻳـــﺢ اﻟﻤـﺆﺟـﺮ ﻟﺴﻨﺔ‬

‫اﻟﺴﻨﺔ‬ ‫اﻟﺸﻬﺮ‬ ‫اﻟﻴﻮم‬ ‫ﺗﺎرﻳﺦ اﻹﺣﺎﻟﺔ‬

‫رﻣﺰ‬ ‫رﻣـﺰ اﻷداء ﻋﻠﻰاﻟﻘﻴﻤﺔ‬ ‫اﻟﻤﻌﺮف اﻟﺠﺒﺎﺋﻲ‬

‫اﻟﺼﻨﻒ‬ ‫اﻟﻤﻀﺎﻓﺔ‬

‫اﻹﺳﻢ واﻟﻠﻘﺐ أو اﻹﺳﻢ اﻹﺟﺘﻤﺎﻋﻲ ‪...............................................................................................................:‬‬

‫اﻟﻌﻨﻮان ‪............................................................................................................................................. :‬‬

‫اﻟﺘﺮﻗﻴﻢ اﻟﺒﺮﻳﺪي‬ ‫‪............................................................................................‬‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﺘﻌﻠﻖ ﺑﺎﻟﺤﺎﻣﻞ ‪:‬‬
‫)‪(1‬‬
‫ﻧﻮﻋﻴﺔ اﻟﺤﺎﻣﻞ‬
‫دﻋﺎﺋﻢ ﻣﻐﻨﺎﻃﻴﺴﻴﺔ ﻟﻠﻤﻌﺎﻟﺠﺔ‬ ‫ﻗﺮص ﻟﻨﻈﺎم اﻟﻘﺮاءة ﺑﺎﻟﻠﻴﺰر‬
‫اﻵﻟﻴﺔ ﻟﻠﻤﻌﻠﻮﻣﺎت‬

‫ﻣﻠﺤﻖ ﻋﺪد ‪V‬‬ ‫ﻣﻠﺤﻖ ﻋﺪد ‪IV‬‬ ‫ﻣﻠﺤﻖ ﻋﺪد ‪III‬‬ ‫ﻣﻠﺤﻖ ﻋﺪد ‪II‬‬ ‫ﻣﻠﺤﻖ ﻋﺪد ‪I‬‬ ‫اﻟﻤﻼﺣﻖ‬
‫اﻟﻤﻼﺣﻖ اﻟﻤﻮدﻋﺔ )‪(1‬‬
‫ﻋﺪد اﻟﻤﻨﺘـﻔـﻌﻴﻦ‬
‫اﻟﻤﺠﻤﻮع اﻟﺼـــﺎﻓﻲ‬
‫اﻟﻮارد ﺑﺎﻟﻤﻠﺤﻖ‬

‫إﻧﻲ اﻟﻤﻤﻀﻲ أﺳﻔﻠﻪ أﺷﻬﺪ ﺑﺼﺤﺔ اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﺘﻀﻤﻨﺔ ﺑﻬﺬا اﻟﺤﺎﻣﻞ‬

‫ﺧﺘﻢ و إﻣﻀﺎء اﻟﻤﺼﺮّح‬

‫‪-----------------------------------------------------------------------------------------------------------------------‬‬

‫ﺗﺼﺤﻴﺤﻲ ﺛﺎﻧﻲ‬ ‫ﺗﺼﺤﻴﺤﻲ أوّل‬ ‫أوّﻟﻲ‬ ‫وﻗــﺘﻲ ‪:‬‬ ‫وﺻﻞ ﺗﺴﻠﻴﻢ )‪: (1‬‬

‫ﻧﻬــﺎﺋﻲ‬

‫ﻳﺸﻬﺪ رﺋﻴﺲ ﻣﻜﺘﺐ ﻣﺮاﻗﺒﺔ اﻷداءات ﺑـ‪......................................................................................................:‬‬

‫أﻧﻪ ﺗﺴﻠﻢ ﻣﻦ اﻟﺴﻴﺪ ‪.............................................................................................................................‬‬
‫ﺣﺎﻣﻞ ﻣﻤﻐﻨﻂ ﻳﺘﻌﻠﻖ ﺑﺘﺼﺮﻳﺢ اﻟﻤﺆﺟﺮ ﻟﺴﻨﺔ ‪...............‬وﻳﺘﻌﻴﻦ ﻋﻠﻰ اﻟﻤﻌﻨﻲ ﺑﺎﻷﻣﺮ اﻹﺗﺼﺎل ﺑﻤﻜﺘﺐ ﻣﺮاﻗﺒﺔ اﻷداءات‬
‫ﻳﻮم‪..................................‬ﻣﻦ ﺷﻬﺮ‪..................‬ﻹﻋﻼﻣﻪ ﺑﻤﺂل اﻟﺤﺎﻣﻞ ‪.‬‬

‫ﺑﺘﺎرﻳﺦ‬
‫اﻟﺴﻨــــﺔ‬ ‫اﻟﺸﻬﺮ‬ ‫اﻟﻴﻮم‬

‫ﺧﺘﻢ وإﻣﻀﺎء رﺋﻴﺲ اﻟﻤﻜﺘﺐ‬

‫‪ (1‬ﺿﻊ )‪ (X‬ﻓﻲ اﻟﻘﺴﻴﻤﺔ اﻟﻤﻨﺎﺳﺒﺔ‬

 ‫اﻹﺳﻢ واﻟﻠﻘﺐ أو اﻹﺳﻢ اﻹﺟﺘﻤﺎﻋﻲ ‪..............................................................................................................:‬‬
‫اﻟﻌﻨﻮان ‪ :‬اﻟﻨﻬﺞ ‪ : ........................................................................‬اﻟﻤﺪﻳﻨﺔ ‪..................................................‬‬

‫اﻟﺘﺮﻗﻴﻢ اﻟﺒﺮﻳﺪي‬ ‫اﻟـﻌـﺪد‬

‫ﻣﻌﻠﻮﻣﺎت ﺗﺘﻌﻠﻖ ﺑﺎﻟﺤﺎﻣﻞ ‪:‬‬

‫ﻧﻮﻋﻴﺔ اﻟﺤﺎﻣﻞ )‪(1‬‬
‫ﻗﺮص ﻣﻌ ّﺪ ﻟﻠﺘﺴﺠﻴﻞ‬ ‫ﻗﺮص ﻟﻨﻈﺎم اﻟﻘﺮاءة‬
‫ﺑﺎﻟﻠﻴﺰر‬

‫إﻧﻲ اﻟﻤﻤﻀﻲ أﺳﻔﻠﻪ أﺷﻬﺪ ﺑﺼﺤﺔ اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﺘﻀﻤﻨﺔ ﺑﻬﺬا اﻟﺤﺎﻣﻞ‬

‫ﺗﻮﻧﺲ ﻓﻲ‬

‫اﻹﻣﻀﺎء‬

‫وﺻﻞ ﺗﺴﻠﻴﻢ ‪:‬‬

‫ﻳﺸﻬﺪ ﻣﻜﺘﺐ ﻣﺮاﻗﺒﺔ اﻷداءات ﺑـــ‪........................................................................:‬‬
‫أﻧﻪ ﺗﺴﻠﻢ ﻣﻦ اﻟﺴﻴﺪ‪............................................................................................‬‬
‫ﺣﺎﻣﻞ ﻣﻤﻐﻨﻂ ﻳﺘﻌﻠﻖ ﺑﺘﺼﺮﻳﺢ اﻟﻤﺆﺟﺮ ﻟﺴﻨﺔ وﻳﺘﻌﻴﻦ ﻋﻠﻰ اﻟﻤﻌﻨﻲ ﺑﺎﻷﻣﺮ اﻹﺗﺼﺎل ﺑﻤﻜﺘﺐ ﻣﺮاﻗﺒﺔ اﻷداءات‬
‫ﻳﻮم‪................./......./.............‬ﻋﻠﻰ اﻟﺴﺎﻋﺔ‪ ..............‬ﻹﻋﻼﻣﻪ ﺑﻤﺂل اﻟﺤﺎﻣــﻞ ‪.‬‬

‫ﺑﺘﺎرﻳﺦ‬
‫اﻟﺴﻨﺔ‬ ‫اﻟﺸﻬﺮ‬ ‫اﻟﻴﻮم‬
‫اﻟﺨﺘﻢ واﻹﻣﻀﺎء‬

‫وﺿﻊ )‪ (X‬ﻓﻲ اﻟﻘﺴﻴﻤﺔ اﻟﻤﻨﺎﺳﺒﺔ‬

‫‪1‬‬