‫)*( ‪1‬‬ ‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺘﻮﻧﺴﻴﺔ‬

‫ﻣﻄﻠﺐ‬
‫ﻷﻭﻝ ﻣﺮّﺓ‬
‫ﺿﻴﺎﻉ‬ ‫‪2‬‬ ‫ﻭﺯﺍﺭﺓ ﺍﻟﺪﺍﺧﻠﻴﺔ‬
‫ﺗﻌﻮﻳﺾ‬ ‫‪3‬‬ ‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﻌﺎﻣﺔ ﻟﻸﻣﻦ ﺍﻟﻮﻃﻨﻲ‬
‫ﺑﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ﺍﻟﻮﻃﻨﻴـﺔ‬
‫ﺭﻗﻢ ﻭﺻﻞ ﺧﻼﺹ‬
‫ﺍﻟﺮﻗـﻢ‬ ‫ﻣﻌﻠﻮﻡ ﺍﻟﻄﺎﺑﻊ ﺍﻟﺠﺒﺎﺋﻲ‬

‫ﺍﻟﺠﻬﺔ‬ ‫ﺍﻟﻌﺪﺩ‬ ‫‪......................................‬‬

‫)*(‬ ‫ﺍﻟﺠﻨﺲ‬ ‫ﺍﻟﻠﻘﺐ ‪..........................................................................................................................................................‬‬

‫ﺃﻧﺜﻰ‬ ‫ﺫﻛﺮ‬ ‫ﺍﻹﺳﻢ ‪.........................................................................................................................................................‬‬
‫ﺇﺳﻢ ﺍﻷﺏ ‪ ..............................................................................‬ﺇﺳﻢ ﺍﻟﺠﺪ ‪.......................................................‬‬
‫ﺍﻟﺤﺎﻟﺔ ﺍﻟﻌﺎﺋﻠﻴﺔ )*(‬ ‫ﻣﻜﺎﻧﻬﺎ ‪..........................................................‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ‬
‫ﺃﻋﺰﺏ‬ ‫ﺍﻟﺴﻨــﺔ‬ ‫ﺍﻟﺸﻬﺮ‬ ‫ﺍﻟﻴﻮﻡ‬
‫ﻣﺘﺰﻭﺝ)ﺓ( ﺃﺭﻣﻞ)ﺓ(‬ ‫‪/‬‬ ‫ﺇﺳﻢ ﺍﻷﻡ‪ ..............................................................................‬ﻟﻘﺒﻬﺎ ‪.............................................................‬‬
‫ﻋﺰﺑﺎﺀ‬
‫ﺇﺳﻢ ﺍﻟﺰﻭﺝ)ﺓ( ‪ .......................................................................‬ﻟﻘﺒﻪ)ﻫﺎ( ‪.........................................................‬‬
‫ﺍﻟﻤﻬﻨﺔ ‪........................................................................................................................................................‬‬
‫ﺍﻟﻔﺼﻴﻠﺔ ﺍﻟﺪﻣﻮﻳﺔ‬ ‫ﻋﻨﻮﺍﻥ ﺍﻟﺴﻜﻨﻰ ‪.............................................................................................................................................‬‬
‫‪ ...........................................................................................‬ﺍﻟﻮﻻﻳﺔ ‪............................................................‬‬

‫‪=IL.01-12/2013=-K«KøKmKfl=–=ÔΟ~^Ñÿ^=Óá^âË‬‬
‫ﺍﻟﻬﻮﻳﺔ ﺍﻟﻘﺪﻳﻤﺔ ‪...........................................................................................................................................‬‬
‫ﻣﺘﺒــــــﺮﻉ )*(‬ ‫ﺇﻥ ﺇﻣﻀﺎﺋﻲ ﺑﻬﺬﺍ ﺍﻟﻤﻠﻒ ﻳﺤﻤﻠﻨﻲ ﻣﺴﺆﻭﻟﻴﺘﻲ ﻭﻳﺠﻌﻠﻨﻲ ﻋﺮﺿﺔ ﻟﻠﺘﺘﺒﻌﺎﺕ‬
‫ﺍﻟﻌﺪﻟﻴﺔ ﻓﻲ ﺻﻮﺭﺓ ﺍﻟﻤﻐﺎﻟﻄﺔ ﺃﻭ ﺍﻟﺘﺰﻭﻳﺮ‬

‫ﺍﻟﺘﻮﻗﻴﻊ ﻭﺟﻮﺑﻲ‬ ‫)*( ﺗﻮﺿﻊ ﻋﻼﻣﺔ ‪ X‬ﻋﻠﻰ ﺍﻟﻤﺮﺑــﻊ ﺍﻟﺼﺤﻴــﺢ‬

‫ﺑﻴﺎﻧـﺎﺕ ﺧﺎﺻﺔ ﺑﺎﻹﺩﺍﺭﺓ‬ ‫ﺑﺼﻤﺔ ﺍﻹﺑﻬﺎﻡ ﺍﻷﻳﻤﻦ‬

‫ﺍﻟﺘﺼﻨﻴﻒ ﺍﻟﺒﺼﻤﻲ‬

‫ﻋﺪﺩ ‪ ..............................................‬ﺣﺮﺭ ﺍﻟﻤﻠﻒ ﻓﻲ ‪........................................................‬‬

‫ﺭﺋﻴﺲ ﺍﻟﻤﺮﻛﺰ‬

‫‬
‫ﻭﺻﻞ ﻓﻲ ﺇﻳﺪﺍﻉ ﺑﻄﺎﻗﺔ ﺍﻟﻌﺮﻳﻒ ﺍﻟﻮﻃﻨﻴﺔ‬
‫ﻟﺼﺎﺣﺒﻪ)ﻫﺎ( ‪...........................................................................................................................................................‬‬
‫ﺳﺠﻞ ﺗﺤﺖ ﻋﺪﺩ ‪ .........................................................‬ﺑﺘﺎﺭﻳﺦ ‪ .....................................‬ﺍﻟﻤﺮﻛﺰ ‪...................................‬‬

‫ﺍﻹﻣﻀﺎﺀ‬
 ‫‪ - 1‬ﺃﺩﺧﻠﺖ ﺍﻟﻤﻌﻄﻴﺎﺕ ﺑﺎﻟﻨّﺎﻇﻢ ﺍﻵﻟﻲ ﻣﻦ ﻃﺮﻑ ﺍﻟﻌﻮﻥ‪:‬‬

‫ﺍﻹﺳﻢ ‪ ................................................................................................................‬ﺍﻹﻣﻀﺎﺀ‪........................................... :‬‬

‫‪ - 2‬ﺃﺩﺧﻠﺖ ﺍﻟﺼّﻮﺭﺓ ﻭﺍﻟﺒﺼﻤﺔ ﺑﺎﻟﻤﻨﻈﻮﻣﺔ ﻣﻦ ﻃﺮﻑ ﺍﻟﻌﻮﻥ‪:‬‬

‫ﺍﻹﺳﻢ ‪ ................................................................................................................‬ﺍﻹﻣﻀﺎﺀ‪........................................... :‬‬

‫ﻋﺪﺩ ‪ ..........................................................................‬ﻳﺤــــﺎﻝ ﻋﻠـــــﻰ ﺍﻟﺴﻴـــــﺪ ﺭﺋﻴــــــــــﺲ ﺍﻹﺩﺍﺭﺓ ﺍﻟﻔﺮﻋﻴــــــــﺔ ﻟﻠﺘﻌﺮﻳــــــــﻒ ﺍﻟﻮﻃﻨــــــــﻲ‬

‫ﺑﻌﺪ ﺍﻹﻧﺠﺎﺯ ﻭﺫﻟﻚ ﻣﻦ ﺃﺟﻞ ‪................................................................................‬‬

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

‫ﻭﻳﺼﻠﻜـــﻢ ﺭﻓﻘﺔ ﻫﺬﺍ‪ ،‬ﺍﻟﻮﺛﺎﺋﻖ ﺍﻟﺘﺎﻟﻴﺔ‪:‬‬

‫ﺷﻬﺎﺩﺓ ﺣﻀﻮﺭ‬ ‫ﻣﻀﻤﻮﻥ ﻭﻻﺩﺓ‬

‫ﺗﺮﺧﻴﺺ ﺃﺑﻮﻱ‬ ‫ﺷﻬﺎﺩﺓ ﻓﻲ ﺍﻟﺠﻨﺴﻴﺔ‬

‫ﺭﺳﻢ ﺯﻭﺍﺝ‬ ‫ﺷﻬﺎﺩﺓ ﺇﻗﺎﻣﺔ‬

‫ﺣﺠّﺔ ﻭﻓﺎﺓ‬ ‫ﺷﻬﺎﺩﺓ ﻋﻤﻞ‬

‫ﺷﻬﺎﺩﺓ ﺿﻴﺎﻉ‬ ‫ﺷﻬﺎﺩﺓ ﺍﻟﻔﺼﻴﻠﺔ ﺍﻟﺪﻣﻮﻳﺔ‬

‫ﺗﺼﺮﻳﺢ ﺑﺎﻟﻤﻮﺍﻓﻘﺔ ﺍﻟﺼﺮﻳﺤﺔ ﻋﻠﻰ ﺍﻟﺘﺒﺮّﻉ ﺑﺎﻷﻋﻀﺎﺀ ﺍﻟﺒﺸﺮﻳﺔ ﺑﻌﺪ ﺍﻟﻮﻓﺎﺓ‬

‫ﺭﺋﻴﺲ ﻓﺮﻗﺔ ﺍﻟﺸﺮﻃﺔ ﺍﻟﻔﻨﻴﺔ ﻭﺍﻟﻌﻠﻤﻴﺔ ﺑـ‪.............................................................:‬‬