‫اﻟﺠﻤﻬﻮرﻳﺔ اﻟﺠﺰاﺋﺮﻳﺔ اﻟﺪﻳﻤﻘﺮاﻃﻴﺔ اﻟﺸﻌﺒﻴﺔ‬

‫وزارة اﻟﺪﻓﺎع اﻟﻮﻃﻨﻲ‬

‫ﻓﻲ ‪ .......................‬ﺏﺘﺎرﻳﺦ ‪................................... :‬‬ ‫ﻡﺪﻳﺮﻳﺔ اﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ‬
‫ﺻﻮرة‬
‫‪NOM : .......................................................................‬‬

‫‪PRÉNOM: ........................................................................‬‬

‫ﺏﻄﺎﻗﺔ اﺳﺘﻌﻼﻡﺎت‬
‫‪ .1‬اﻟﺤﺎﻟﺔ اﻟﻤﺪﻥﻴﺔ ‪:‬‬
‫اﻻﺳﻢ‪ ........................................... :‬اﻟﻠﻘﺐ ‪ .......................................... :‬رﻗﻢ اﻟﺘﺴﺠﻴﻞ ‪........................................... :‬‬
‫ﺕﺎرﻳﺦ اﻟﻤﻴﻼد‪............................ ................................. :‬ﻡﻜﺎن اﻟﻤﻴﻼد ‪............................................................. ..... :‬‬
‫اﺏﻦ‪............................ ............................................ :‬و‪............................................................. .....................‬‬
‫اﻟﻌﻨﻮان‪ ......... ...................... ............................ ........................................ :‬وﻻﻳﺔ ‪...........................................:‬‬
‫اﻟﻤﺴﺘﻮى اﻟﺪراﺳﻲ‪ ............................ ...........................:‬اﻟﺪﺏﻠﻮم اﻟﻤﺘﺤﺼﻞ ﻋﻠﻴﻪ ‪................................................... .. :‬‬
‫ﺕﺎرﻳﺦ ﻥﻬﺎﻳﺔ اﻟﺪراﺳﺔ‪ ............................ ........................ :‬اﻟﻤﻬﻨﺔ ‪................................................... ......... ............ :‬‬
‫ﻡﺘﺰوج‪/‬أﻋﺰب‪............................ ................................ :‬ﻋﺪد اﻷﻃﻔﺎل ‪................................................... ......... ..... :‬‬
‫‪ .2‬اﻟﻮﺿﻌﻴﺔ إزاء اﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ ‪:‬‬
‫أ‪ .‬اﻟﻤﺼﺮح ﺏﻬﺎ ﻡﻦ ﻃﺮف اﻟﻤﻮاﻃﻦ‪:‬‬
‫ﻓﻲ اﻥﺘﻈﺎر اﻟﻤﺮور أﻡﺎم ﻟﺠﻨﺔ اﻹﻋﻔﺎء‬ ‫ﻡﺆﺝﻞ إﻟﻰ ﻏﺎﻳﺔ ‪2003-12-31‬‬
‫ﻟﻢ ﻳﻜﻦ ﻡﺤﻞ أﻡﺮ اﺳﺘﺪﻋﺎء‬ ‫ﻡﺴﺘﺪﻋﻰ ﻟﻢ ﻳﻠﺘﺤﻖ ﺏﺎﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ‬
‫ﻟﻢ ﻳﺴﺘﺠﺐ ﻟﻼﺳﺘﺪﻋﺎء ﻹﺝﺮاء اﻟﻔﺤﺺ اﻟﻄﺒﻲ ﻟﺘﺤﺪﻳﺪ أهﻠﻴﺘﻪ‬ ‫ﻡﺆﺝﻞ ﻟﻢ ﻳﺠﺪد اﻟﺘﺄﺝﻴﻞ ﺏﻌﺪ ‪2002-12-31‬‬
‫ﻟﻢ ﻳﺴﺘﺪع ﻹﺝﺮاء اﻟﻔﺤﺺ اﻟﻄﺒﻲ ﻟﻼﻥﺘﻘﺎء‬
‫ﺕﻮﻗﻴﻊ اﻟﻤﻌﻨﻲ‪:‬‬

‫ﻡﻼﺡﻈﺔ ‪ :‬آﻞ ﺕﺼﺮﻳﺢ ﻡﺰور ﻳﺆدي ﺏﺼﺎﺡﺒﻪ‪،‬ﺏﺎﻹﺿﺎﻓﺔ إﻟﻰ ﻡﺘﺎﺏﻌﺎت ﻡﺤﺘﻤﻠﺔ إﻟﻰ ﻓﻘﺪان آﻞ اﻟﺤﻘﻮق ﺥﺎﺻﺔ ﻡﻨﻬﺎ اﻻﺳﺘﻔﺎدة ﻡﻦ ﺏﻄﺎﻗﺔ ﻡﺆهﻞ‬
‫ﻻ ﻳﺠﻨﺪ‪.‬‬

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‫ب‪ .‬اﻟﻮﺿﻌﻴﺔ اﻟﻔﻌﻠﻴﺔ ﻟﻠﻤﻮاﻃﻦ ﺏﻌﺪ اﻹﻃﻼع ﻋﻠﻰ ﻡﻠﻔﻪ‪:1‬‬
‫‪NE RIEN NOTER DANS CE CADRE‬‬
‫ﻓﻲ اﻥﺘﻈﺎر اﻟﻤﺮور أﻡﺎم ﻟﺠﻨﺔ اﻹﻋﻔﺎء‬ ‫ﻡﺆﺝﻞ إﻟﻰ ﻏﺎﻳﺔ ‪2002-12-31‬‬
‫ﻟﻢ ﻳﻜﻦ ﻡﺤﻞ أﻡﺮ اﺳﺘﺪﻋﺎء‬ ‫ﻡﺴﺘﺪﻋﻰ ﻟﻢ ﻳﻠﺘﺤﻖ ﺏﺎﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ‬
‫ﻟﻢ ﻳﺴﺘﺠﺐ ﻟﻼﺳﺘﺪﻋﺎء ﻹﺝﺮاء اﻟﻔﺤﺺ اﻟﻄﺒﻲ ﻟﺘﺤﺪﻳﺪ أهﻠﻴﺘﻪ‬ ‫ﻡﺆﺝﻞ ﻟﻢ ﻳﺠﺪد اﻟﺘﺄﺝﻴﻞ ﺏﻌﺪ ‪2002-12-31‬‬
‫ﻡﻘﺘﺮف اﻟﻌﺼﻴﺎن إزاء اﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ‬ ‫ﻟﻢ ﻳﺴﺘﺪع ﻹﺝﺮاء اﻟﻔﺤﺺ اﻟﻄﺒﻲ ﻟﻼﻥﺘﻘﺎء‬
‫‪RESERVE‬‬ ‫‪AUX‬‬ ‫‪SERVICES‬‬ ‫‪DU‬‬
‫ﺕﻮﻗﻴﻊ ﻗﺎﺋﺪ ﻡﺮآﺰ اﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ‪:‬‬ ‫‪MINISTERE‬‬ ‫‪DE‬‬ ‫‪LA‬‬ ‫‪DEFENSE‬‬ ‫‪NATIONALE‬‬

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‫‪ .3‬وﺻﻞ اﺳﺘﻼم ‪:‬‬
‫أﻥﺎ اﻟﻤﻮﻗﻊ أﺳﻔﻠﻪ‪.......................................................... :‬رﻗﻢ اﻟﺘﺴﺠﻴﻞ‪.................................. ................................ :‬‬
‫أﺻﺮح ﺏﺎﺳﺘﻼﻡﻲ ﺏﻄﺎﻗﺔ اﻹﻋﻔﺎء ﻡﻦ اﻟﺨﺪﻡﺔ اﻟﻮﻃﻨﻴﺔ اﻟﺘﻲ أﻋﺪت ﻟﻲ‬
‫ﻳﻮم ‪ ............................................ :‬ﺕﺤﺖ ‪ ...................... .................... :‬ﻡﺮﺝﻊ اﻟﻮﺛﻴﻘﺔ اﻟﻤﻘﺪﻡﺔ‪... ................................ :‬‬
‫ﺡﺮر ﻓﻲ‪ ................................... :‬ﺏﺘﺎرﻳﺦ‪................. ....................................................... :‬‬

‫‪ 1‬ﺥﺎﺻﺔ ﺏﻤﻜﺘﺐ اﻟﻤﻮرد‬