‫اﻟـﺠﻤﮭﻮرﯾـــﺔ اﻟـﺠﺰاﺋﺮﯾــــﺔ اﻟـﺪﯾﻤﻘﺮاﻃﯿــــﺔ‬

‫اﻟـﺸﻌﺒﯿـــــﺔ‬

‫ﺗﺼﺮﯾﺢ ﺑﻌﺪم‬
‫اﻟﻌﻤﻞ‬

‫اﻟﺳﯾــد)ة(‪...............................................................................................:‬‬ ‫أﻧﺎ اﻟﻣﻣﺿﻲ أﺳﻔﻠـﮫ‬

‫ﺑﺗﺎرﯾـﺦ‪ .......................................:‬ﺑــ‪................................................................:‬‬ ‫اﻟﻣوﻟـود )ة(‬
‫رﻗــم‪............................................................................:‬‬ ‫واﻟﺣﺎﻣـل)ة( ﻟـ )ب‪.‬ت‪.‬و(‪)/‬ر‪.‬س(‬
‫داﺋــرة‪.............................................................:‬‬ ‫اﻟﺻـﺎدرة ﺑﺗﺎرﯾـﺦ‪.......................................:‬ﻋن‬
‫وﻻﯾــــــــﺔ‪.................................................................................................................................:‬‬

‫ﺑــ‪.....................................................................................................................:‬‬ ‫اﻟﺳﺎﻛــن)ة(‬
‫أﺻــرح ﺑﺷرﻓــﻲ ﺑﺄﻧﻧـﻲ ﺑدون ﻋﻣــل وﻻ أﺗﻘﺎﺿـﻰ أﯾـﺔ ﻣﻧﺣــﺔ‪.‬‬

‫ﺑﺗﺎرﯾــﺦ‪..........................................:‬‬ ‫ﺣرر‬

‫ﻣﺻــﺎدﻗﺔ اﻟﺑﻠدﯾــﺔ‬ ‫إﻣﺿــﺎء اﻟﻣﻌﻧـﻲ‬