‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺘﻮﻧﺴﻴﺔ‬

‫ﻭﺯﺍﺭﺓ ﺍﻟﺪﺍﺧﻠﻴﺔ‬
‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﻌﺎﻣﺔ ﻟﻸﻣﻦ ﺍﻟﻮﻃﻨﻲ‬

‫ﻣﻄﻠﺐ ﺑﻄﺎﻗـــﺔ ﻋــﺪﺩ ‪3‬‬

‫)ﻧﻈﲑ ﻣﻦ اﻟﺴﻞ اﻟﻌﺪﱄ(‬ ‫ﻣﺮﻛﺰ )‪................................................: (1‬‬

‫____*____‬ ‫_______________‬

‫ﺍﻟﻤﺴﻤﻰ)ﺓ(‪.....................................................‬ﺑﻦ)ﺕ(‪....................................................................‬ﺑﻦ‪.....................................................‬‬
‫)ﺍﺳﻢ ﺍﻟﺠﺪ(‬ ‫)ﺍﺳﻢ ﺍﻷﺏ(‬ ‫)ﺍﺳﻢ ﺍﻟﻄﺎﻟﺐ(‬

‫ﺍﻟﻠﻘﺐ ‪.................................................................................................................................................................................................‬‬
‫)ﺍﻟﻠﻘﺐ ﺍﻟﻌﺎﺋﻠﻲ ﺃﻭ ﺇﺳﻢ ﺍﻟﺠﺪ(‬

‫‪.....................................................................‬‬
‫)ﺍﺳﻢ ﺍﻷﺏ(‬

‫‪ ....................................................................‬ﺑﻨﺖ ‪...............................................................................................................................‬‬
‫)ﻟﻘﺐ ﺍﻷﻡ(‬ ‫)ﺍﺳﻢ ﺃﺏ ﺍﻷﻡ(‬ ‫)ﺍﺳﻢ ﺍﻷﻡ(‬

‫ﺍﻟﻤﻮﻟﻮﺩ)ﺓ( ﻓـﻲ ‪ ................................‬ﺑـ‪ .................................‬ﻣﻌﺘﻤﺪﻳﺔ ‪.....................................‬ﻭﻻﻳﺔ ‪...................................................‬‬

‫)ﻣﻜﺎﻥ ﺍﻟﻮﻻﺩﺓ(‬ ‫)ﺗﺎﺭﻳﺦ ﺍﻟﻮﻻﺩﺓ(‬

‫‪=IL.03-12/2013=-K«KøKmKfl=–=ÔΟ~^Ñÿ^=Óá^âË‬‬
‫ﻣﺘﺰﻭﺝ)ﺓ( ﺑـ‪.........................................................................................................................................................................................‬‬

‫ﻋﺪﺩ ﺍﻻﺑﻨﺎﺀ ‪.........................................................................................................................................................................................‬‬

‫ﺍﻟﻘﺎﻃﻦ)ﺓ( ﺑـ‪........................................................................................................................................................................................‬‬
‫)ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ(‬

‫ﺍﻟﺤﺮﻓﺔ ‪..............................................................................................................................................................................................‬‬

‫)‪ (1‬ﺫﻛﺮ ﺍﺳﻢ ﺍﻟﻤﺮﻛﺰ ﺑﺎﻟﻤﻄﺒﻮﻋﺔ‬

‫‬
‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺘﻮﻧﺴﻴﺔ‬
‫ﻭﺻﻞ ﻓﻲ ﺍﻳﺪﺍﻉ ﻣﻄﻠﺐ ﺑﻄﺎﻗﺔ ﻋﺪﺩ ‪3‬‬ ‫ﻭﺯﺍﺭﺓ ﺍﻟﺪﺍﺧﻠﻴﺔ‬
‫____*____‬ ‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﻌﺎﻣﺔ ﻟﻸﻣﻦ ﺍﻟﻮﻃﻨﻲ‬
‫____*____‬
‫ﻣﺮﻛﺰ ‪................................‬‬
‫ﻋـ‪. . . . . . . .‬ﺩﺩ‬
‫ﺍﻟﺴﻠﻄﺔ ﺍﻟﻤﺴﺨﺮﺓ ﺍﻟﻤﻜﻠﻔﺔ‬
‫ﺑﺘﺴﻠﻴﻢ ﺍﻟﺒﻄﺎﻗﺔ ﻋﺪﺩ ‪3‬‬
‫ﺍﻟﻤﺴﻤــﻰ)ﺓ(‪.........................................................................................................‬‬
‫ﺍﻟﻘﺎﻃﻦ)ﺓ( ﺑـ‪..........................................................................................................‬‬
‫ﺗﺎﺭﻳﺦ ﺍﻳﺪﺍﻉ ﺍﻟﺒﻄﺎﻗﺔ ﻋﺪﺩ ‪......................................................................................3‬‬

‫ﺧﺘﻢ ﻭﺇﻣﻀﺎﺀ ﺭﺋﻴﺲ ﺍﻟﻤﺮﻛﺰ‬

 ‫ﻋﺪﺩ ﻭﺻﻞ ﺧﻼﺹ ﻣﻌﻠﻮﻡ ﺍﻟﻄﺎﺑﻊ ﺍﻟﺠﺒﺎﺋﻲ‪ .................................‬ﺍﻟﺼﺎﺩﺭ ﺑﺎﻟﻘﺒﺎﺿﺔ ﺍﻟﻤﺎﻟﻴﺔ ‪ ..................................‬ﺑﺘﺎﺭﻳﺦ ‪.............................‬‬

‫ﺷﻬﺎﺩﺓ ﻓﻲ ﺍﻟﺤﺎﻟﺔ ﺍﻟﻌﺴﻜﺮﻳﺔ )‪ (2‬ﻋﺪﺩ ‪ .......................................‬ﺑﺘﺎﺭﻳﺦ‪ ............................‬ﺍﻻﺳﺒﺎﺏ‪.......................................................‬‬

‫ﻣﻀﻤﻮﻥ ﺍﻟﺤﺎﻟﺔ ﺍﻟﻤﺪﻧﻴﺔ)‪ (3‬ﻋﺪﺩ ‪ ......................‬ﻣﺴﻠﻢ ﻓﻲ ‪ ............................‬ﺑـ ‪......................‬‬ ‫ﺣﺠﺔ ﺍﻟﺤﺎﻟﺔ ﺍﻟﻤﺪﻧﻴﺔ‬
‫)ﺍﻟﺘﺎﺭﻳﺦ(‬

‫ﺑﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ﻋﺪﺩ)‪ ................. (4‬ﻣﺴﻠﻤﺔ ﻓﻲ ‪ ............................‬ﺑـ ‪...............................‬‬ ‫ﺍﻟﻤﻘﺪﻣﺔ ﻣﻦ ﻃﺮﻑ ﺍﻟﻤﻌﻨﻲ)ﺓ( ﺑﺎﻷﻣﺮ‬
‫)ﺍﻟﺘﺎﺭﻳﺦ(‬

‫ﻳـ)ﺗـ(ﺷﻬﺪ ﺍﻟﻄﺎﻟﺐ)ﺓ( ﻭﺃﻥ ﺍﻟﺤﺎﻟﺔ ﺍﻟﻤﺪﻧﻴﺔ ﺍﻟﻤﺬﻛﻮﺭﺓ ﺗﻨﻄﺒﻖ ﻋﻠﻴﻪ)ﻫﺎ( ﺩﻭﻥ‬ ‫ﻳﺸﻬﺪ ﺭﺋﻴﺲ ﺍﻟﻤﺮﻛﺰ )‪......................... (5‬‬
‫ﺳﻮﺍﻩ)ﻫﺎ(‬ ‫ﺑـ‪ .............................‬ﻭ ﺃﻥ ﺍﻟﺤﺎﻟﺔ ﺍﻟﻤﺪﻧﻴﺔ‬
‫ﻣﻄﺎﺑﻘﺔ ﻟﻠﻮﺛﻴﻘﺔ ﺍﻟﻤﻘﺪﻣﺔ‬
‫ﺍﻹﻣﻀﺎﺀ ﺃﻭ ﺍﻟﺒﺼﻤﺔ ﻟﻠﻤﻌﻨﻲ)ﺓ( ﺑﺎﻷﻣﺮ‬
‫ﺗﻮﻧﺲ ﻓﻲ ‪..........................................‬‬

‫ﺍﻹﻣﻀﺎﺀ ﻭﺍﻟﻄﺎﺑﻊ‬

‫)‪ (2‬ﺑﺎﻟﻨﺴﺒﺔ ﺇﻟﻰ ﺍﻟﻤﻮﺍﻃﻨﻴﻦ ﺍﻟﺘﻮﻧﺴﻴﻴﻦ ﺍﻟﻤﻠﺰﻣﻴﻦ ﺑﺎﻟﺨﺪﻣﺔ ﺍﻟﻌﺴﻜﺮﻳﺔ‬

‫)‪ (3‬ﺑﺎﻟﻨﺴﺒﺔ ﺇﻟﻰ ﺟﻤﻴﻊ ﻣﻮﺍﻟﻴﺪ ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺘﻮﻧﺴﻴﺔ‬
‫)‪ (4‬ﺑﺎﻟﻨﺴﺒﺔ ﺇﻟﻰ ﺍﻟﻤﺴﺘﻮﻃﻨﻴﻦ ﺍﻟﺘﺎﺑﻌﻴﻦ ﻟﺒﻠﺪﺍﻥ ﺍﻟﻤﻐﺮﺏ ﺍﻟﻌﺮﺑﻲ ﻭﺍﻟﻤﺴﻠﻤﻴﻦ ﻣﻦ ﺍﻟﻌﺮﺏ ﻋﺎﻣﺔ ﺍﻟﻤﻮﻟﻮﺩﻳﻦ ﺑﺎﻟﺨﺎﺭﺝ‪ :‬ﺍﻟﺘﻌﺮﺽ ﺇﻟﻰ ﺫﻛﺮ ﻋﺪﺩ ﺑﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ‪،‬ﻭﺗﺎﺭﻳﺦ ﺗﺴﻠﻴﻤﻬﺎ ‪،‬ﻭﺍﻟﺴﻠﻄﺔ ﺍﻟﻤﺼﺪﺭﺓ ﻭﺇﺭﺟﺎﻉ ﺍﻟﺒﻄﺎﻗﺔ ﻟﺼﺎﺣﺒـ)ﺗـ(ﻫﺎ ﺩﻭﻥ‬
‫ﺍﺿﺎﻓﺘﻬﺎ ﻟﻠﻤﻄﻠﺐ‬
‫)‪ (5‬ﺫﻛﺮ ﺍﺳﻢ ﺍﻟﻤﺮﻛﺰ ﺑﺎﻟﻤﻄﺒﻮﻋﺔ‬