‫ا

ر
 ا‬
‫وزارة ا ‬
‫ادارة اﻡ 
ا‬

‫ﻡ‪!" #$‬ل  ر ا

 ى ا
ا‬
‫ﺹ ﺍﻝﻁﺎﻝﺏ ‪:‬‬
‫ﺒﻴﺎﻨﺎﺕ ﺘﺨ ‪‬‬
‫‪.......................................‬‬‫ﺍﻻﺴﻡ ﻭﺍﻝﻠﻘﺏ ﺃﻭ ﺍﻻﺴﻡ ﺍﻻﺠﺘﻤﺎﻋﻲ‪...................................................................................:‬ﺍﻝﺠﻨﺴﻴﺔ‪:‬‬
‫ﺍﺴﻡ ﺍﻝﻤﻤﺜل ﺍﻝﻘﺎﻨﻭﻨﻲ ﻝﻠﻤﺅﺴﺴﺔ‪.............................................................................................................................................. :‬‬

‫ﺍﻝﻌﻨﻭﺍﻥ ﺃﻭ ﺍﻝﻤﻘﺭ ﺍﻻﺠﺘﻤﺎﻋﻲ‪................................................................................................................................................ :‬‬

‫ﺍﻝﻭﻻﻴﺔ‪..................................................................................... :‬ﺍﻝﺘﺭﻗﻴﻡ ﺍﻝﺒﺭﻴﺩﻱ‪................................................................... :‬‬

‫ﺭﻗﻡ ﻭﺜﻴﻘﺔ ﺍﻝﻬﻭﻴﺔ )‪.............................................................................................................................................................. :(1‬‬

‫ﺍﻝﻬﺎﺘﻑ‪ ................................................................................... :‬ﺍﻝﻔﺎﻜﺱ‪................................................................................. :‬‬

‫ﺒﻴﺎﻥ ﺍﻝﻨﺸﺎﻁ‪ ...................................................................................................................... :‬ﺍﻝﺭﻤﺯ‪....................................... :‬‬

‫ﺘﺼﻨﻴﻔﺔ ﺍﻝﻨﺸﺎﻁ‪ ................................................................................................................... :‬ﺍﻝﺭﻤﺯ‪...................................... :‬‬

‫ﻋﻨﻭﺍﻥ ﻤﺤﻼﺕ ﺍﻝﺨﺯﻥ‪........................................................................................................................................................... :‬‬

‫ﺍﻝﺼﻔﺔ ﻤﻥ ﺍﻝﻨﺎﺤﻴﺔ ﺍﻝﻘﺎﻨﻭﻨﻴﺔ ﻭﺍﻝﺼﺭﻓﻴﺔ‪:‬‬

‫ﻨﻅﺎﻡ ﺍﻝﺼﺭﻑ‬ ‫ﻁﺒﻴﻌﺔ ﺍﻝﻤﺅﺴﺴﺔ)‪(2‬‬ ‫ﺍﻝﻤﺤﻜﻤﺔ‬ ‫ﺍﻝﺭﻗﻡ ﺒﺎﻝﺴﺠل ﺍﻝﺘﺠﺎﺭﻱ‬
‫ﻏﻴﺭ ﻤﻘﻴﻡ‬ ‫ﻤﻘﻴﻡ‬ ‫ﻏﻴﺭﻩ‬ ‫ﺸﺨﺹ ﻁﺒﻴﻌﻲ‬ ‫ﺵ‪.‬ﺵ‪.‬ﻭ‬ ‫ﺵ‪.‬ﻡ‪.‬ﻡ‬ ‫ﺵ‪.‬ﺥ‪.‬ﺇ‬

‫‪07-01.39-02‬‬
‫ﺍﻝﺼﻔﺔ ﻤﻥ ﺍﻝﻨﺎﺤﻴﺔ ﺍﻝﺠﺒﺎﺌﻴﺔ‪:‬‬
‫ﻁﺒﻴﻌﺔ ﺍﻝﻨﻅﺎﻡ ﺍﻝﺠﺒﺎﺌﻲ ﻤﻥ‬ ‫ﺍﻝﻨﻅﺎﻡ ﺍﻝﺠﺒﺎﺌﻲ ﻤﻥ ﺤﻴﺙ ﺍﻷﺩﺍﺀ ﻋﻠﻰ ﺍﻝﻘﻴﻤﺔ ﺍﻝﻤﻀﺎﻓﺔ‬ ‫ﺭﻗﻡ ﺍﻝﻔﺭﻉ‬ ‫ﺭﻤﺯ‬ ‫ﻤﻌﺭﻑ ﺍﻻﺩﺍﺀ‬ ‫ﺍﻝﻤﻌﺭﻑ ﺍﻝﺠﺒﺎﺌﻲ‬
‫ﻨﺎﺤﻴﺔ ﺍﻷﺩﺍﺀﺍﺕ ﺍﻝﻤﺒﺎﺸﺭﺓ‬ ‫ﺍﻝﺜﺎﻨﻭﻱ‬ ‫ﺍﻝﺼﻨﻑ‬ ‫ﻋﻠﻰ ﺍﻝﻘﻴﻤﺔ‬
‫ﻥ‪ .‬ﺘﻘﺩﻴﺭﻱ ﻏﻴﺭﻩ‬ ‫ﻥ‪ .‬ﺤﻘﻴﻘﻲ‬ ‫ﻏﻴﺭ ﺨﺎﻀﻊ‬ ‫ﺨﺎﻀﻊ ﺒﺎﻻﺨﺘﻴﺎﺭ‬ ‫ﺨﺎﻀﻊ ﺇﺠﺒﺎﺭﻱ‬ ‫ﺍﻝﻤﻀﺎﻓﺔ‬

‫ﻝﺠﺯﺀ ﻤﻥ ﻨﺸﺎﻁﻪ‬ ‫ﻝﻤﺠﻤل ﻨﺸﺎﻁﻪ‬

‫ﺘﺎﺭﻴﺦ ﺍﻝﺘﺼﺭﻴﺢ ﺒﺎﻝﻭﺠﻭﺩ‪:‬‬

‫‪.........................................................................................‬‬

‫‪:‬‬
‫)‪............................................................................... (3‬‬ ‫ﺍﻝﺼﻔﺔ ﻤﻥ ﺍﻝﻨﺎﺤﻴﺔ ﺍﻝﺩﻴﻭﺍﻨﻴﺔ‬
‫ﺍﻝﺘﺯﺍﻡ ‪ :‬ﺇﻨﻲ ﺍﻝﻤﻤﻀﻲ ﺃﺴﻔﻠﻪ ﺃﺼ ‪‬ﺭﺡ ﻋﻠﻰ ﺸﺭﻓﻲ ﺒﺄﻥ ﺍﻝﻤﻌﻠﻭﻤﺎﺕ ﺍﻝﻤﺒﻴ‪‬ﻨﺔ ﺃﻋﻼﻩ ﺼﺤﻴﺤﺔ ﻭﺃﻝﺘﺯﻡ ﺒﺄﻥ ﺃﻋﻠﻡ ﺍﻹﺩﺍﺭﺓ‬
‫ل ﺘﻐﻴﻴﺭ ﻴﻁﺭﺃ ﻋﻠﻰ ﻫﺫﻩ ﺍﻝﻤﻌﻠﻭﻤﺎﺕ‪.‬‬
‫ﺍﻝﻌﺎﻤﺔ ﻝﻠﺩﻴﻭﺍﻨﺔ ﺒﻜ ّ‬
‫‪..........................‬‬ ‫ﻓﻲ‬ ‫ﺤﺭﺭ ﺒـ‬
‫‪.................................‬‬
‫ﺍﻹﻤﻀﺎﺀ‬ ‫ﺍﻻﺴﻡ ﻭﺍﻝﻠﻘﺏ ﻭﺍﻝﺼﻔﺔ‬

‫ﺇﻁﺎﺭ ﺨﺎﺹ ﺒﺎﻹﺩﺍﺭﺓ‪:‬‬

‫ﺍﻝﻘﻁﺎﻉ ﺍﻻﻗﺘﺼﺎﺩﻱ‪:‬‬
‫‪.................................................................................................................‬‬

‫ﻤﻼﺤﻅﺎﺕ ‪ .............................................................................................................................:‬ﺭﻗﻡ ﺍﻝﺘﻌﺭﻴﻑ ﻝﺩﻯ ﺍﻝﺩﻴﻭﺍﻨﺔ‬

‫ﺃﻨﺠﺯ ﺒـ )‪.................................................: (4‬ﻓﻲ‪...................................................................:‬‬

‫ـــــــــــــــــــــــــــــــــــــــــــــــــــــــ‬
‫)‪ (3‬أذآ ا  م ا 
ا  &‪%‬ﺱ‪:‬‬ ‫)‪ (1‬ر  ا  ا
   
‬
‫)ﻡ
دع ‪ ،6‬ﻡ
دع ‪ ،72‬ﻡ
دع ‪ ،556‬ﻡ
دع ‪
2‬ري‪ ،‬ا &ﻡ‪ /‬ا ‬ ‫ر (
از ا ‪ -‬أو  ا‪+‬ﻡ   )(‬
‫ﺕ‪B‬ه ﻡ@ ? ا 
ا ‪ ،‬ﻡ>زن وﻡ‪6‬ت ا ? ا 
ا ‪ ،‬م ‪7‬م‪(...FG ،‬‬ ‫)‪ (2‬ش‪.‬خ‪.‬إ‪B :‬آ ‪ -E‬ا‪D‬ﺱ‬
‫)‪ (4‬ﻡ‪ MN‬ا 
ا  ا ‪L‬ي م &? ا ﻡ‪ K‬ا 
ا ‪.‬‬ ‫ش‪.‬م‪.‬م‪B :‬آ ذات ﻡ‪%‬و  ﻡ‪J‬ودة‪.‬‬
‫ش‪.‬ش‪.‬و‪B :‬آ ا ‪ O>P‬ا
ا‪.6‬‬