‫ﻣﺤﻀﺮ اﺳﺘﻼم ﻣﺤﻄﺔ ﻣﺤﺮوﻗﺎت )‪(......................

‬‬
‫اﻧﻪ ﻓﻲ ﻳﻮم ‪..........................‬ﺑﺘﺎرﻳﺦ ‪..........................‬ﻫـ‪ ،‬اﻟﻤﻮاﻓﻖ ‪..........................‬م‪ ،‬ﺗﻢ اﻟﻮﻗﻮف ﻋﻠﻰ ﻣﺤﻄﺔ‬
‫اﻟﻤﺤﺮوﻗﺎت اﻟﻤﺴﻤﺎة ﺑﻤﺤﻄﺔ )‪ (...............‬ﺑﻤﺪﻳﻨﺔ ‪ .......................‬ﺣﻲ ‪ .......................‬ﻋﻠﻰ ﺷﺎرع ‪ .......................‬وﺗﺤﻤﻞ‬
‫ﺗﺮﺧﻴﺺ دﻓﺎع ﻣﺪﻧﻲ ﺗﺤﺖ اﻟﺮﻗﻢ )‪ (.......................‬ﺑﺘﺎرﻳﺦ ‪ .......................‬ﻫـ‪ ،‬وﺗﺮﺧﻴﺺ اﻟﺒﻠﺪﻳﺔ ﺗﺤﺖ اﻟﺮﻗﻢ‬
‫)‪ (.......................‬ﺑﺘﺎرﻳﺦ ‪ .......................‬ﻫـ‪ ،‬وذﻟﻜﻢ ﻗﺒﻞ اﻟﺴﻴﺪ ﺻﺎﺣﺐ اﻟﻤﺤﻄﺔ او ﻣﻦ ﻳﻨﻮب ﻋﻨﻪ ﺑﻮﻛﺎﻟﺔ ﺷﺮﻋﻴﺔ‬
‫ﺳﺎرﻳﺔ اﻟﻤﻔﻌﻮل وﻣﻨﺪوﺑﻲ ﺷﺮﻛﺔ ‪ ....‬واﻟﺘﻲ ﻗﺎﻣﺖ ﺑﺎﺳﺘﺌﺠﺎر اﻟﻤﺤﻄﺔ اﻟﺬﻛﻮرة أﻋﻼه ﺣﺴﺐ اﻟﻌﻘﺪ اﻟﻤﺒﺮم ﺑﻴﻦ‬
‫ﺻﺎﺣﺐ اﻟﻤﺤﻄﺔ وﺷﺮﻛﺔ ﻓﻴﻮﻟﻜﺲ وﻟﻘﺪ ﺗﻢ اﻻﺳﺘﻼم واﻟﺘﺴﻠﻴﻢ ﻟﻠﻤﺤﻄﺔ اﻟﻤﻌﻨﻴﺔ ﻋﻠﻰ اﻟﻨﺤﻮ اﻟﺘﺎﻟﻲ‪:‬‬

‫‪ (1‬ﻃﺮﻣﺒﺎت اﻟﻮﻗﻮد‪:‬‬
‫ﻳﻮﺟﺪ ﺑﺎﻟﻤﺤﻄﺔ ﻋﺪد )‪ (....‬ﻃﺮﻣﺒﺔ ﺗﻤﻮﻳﻦ ﺳﻴﺎرات ﻣﻨﻬﺎ )‪ (.....‬ﻣﺰدوج ﻣﻔﺼﻠﺔ ﻋﻠﻰ اﻟﻨﺤﻮ اﻟﺘﺎﻟﻲ‪:‬‬

‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫ﻗﺮاءة اﻟﻌﺪاد اﻟﺴﺮي‬ ‫اﻟﻌﺪد‬ ‫ﻧﻮع اﻟﻄﺮﻣﺒﺔ‬

‫‪ (2‬اﻟﺨﺰاﻧﺎت‪:‬‬
‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫اﻟﺴﻌﺔ اﻟﺘﺸﻐﻴﻠﻴﺔ‬ ‫ﻧﻮع اﻟﻮﻗﻮد‬ ‫رﻗﻢ اﻟﺨﺰان‬
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‫‪4‬‬

‫‪ (3‬اﻟﻄﺮﻣﺒﺎت اﻟﻐﻄﺎﺳﺔ‪:‬‬
‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫ﻗﻮة اﻟﻐﺎﻃﺲ‬ ‫ﻋﺪدﻫﺎ‬ ‫ﻣﺎرﻛﺔ اﻟﻐﺎﻃﺲ‬

‫‪ (4‬ا‪U‬ﺟﻬﺰة‪:‬‬

‫اﻟﻤﻼﺣﻈﺎت‬ ‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫اﻟﻤﻮاﺻﻔﺎت‬ ‫اﻟﻌﺪد‬ ‫ﻧﻮع اﻟﺠﻬﺎز‬

‫اﻟﺮواﻓﻊ‬
‫ﺿﻮاﻏﻂ اﻟﻬﻮاء‬
‫ﺑﻜﺮات اﻟﺘﺰﻳﻴﺖ‬
‫واﻟﺘﺸﺤﻴﻢ‬
‫ﻣﻀﺨﺎت اﻟﻤﻴﺎه‬
‫ﻣﻌﺪات اﻻﻣﻦ واﻟﺴﻼﻣﺔ‬

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 ‫‪ (5‬اﻟﻤﺒﺎﻧﻲ‪:‬‬
‫ﻳﻮﺟﺪ ﻋﺪد )‪ (.....‬ﺣﻔﺮ ﻏﻴﺎر زﻳﻮت وﻋﺪد)‪ (....‬رواﻓﻊ ﻏﻴﺎر زﻳﻮت وﺣﺎﻟﺘﻬﺎ اﻟﺮاﻫﻨﺔ )‪(........‬‬
‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫ﻏﺮض اﻻﺳﺘﻌﻤﺎل‬ ‫ﻧﻮع اﻟﻤﺒﺎﻧﻲ‬

‫‪ (6‬ﻋﺪادات اﻟﻜﻬﺮﺑﺎء واﻟﻤﻴﺎه‪:‬‬

‫اﻟﻘﺪرة‬ ‫م‬
‫اﻟﺤﺎﻟﺔ اﻟﻔﻨﻴﺔ‬ ‫رﻗﻢ اﻻﺷﺘﺮاك‬ ‫اﻟﻘﺮاءة اﻟﺤﺎﻟﻴﺔ‬ ‫ﻧﻮع اﻟﻌﺪاد‬ ‫رﻗﻢ اﻟﻌﺪاد‬
‫اﻟﺘﺸﻐﻴﻠﻴﺔ‬
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‫ﺳﻴﺘﻢ ﻋﻤﻞ ﺗﺼﻔﻴﺔ ﻛﺎﻣﻠﺔ ﻟﻌﺪادات اﻟﻜﻬﺮﺑﺎء واﻟﻤﺎء ﻣﻦ ﻗﺒﻞ ﻣﺎﻟﻚ اﻟﻤﺤﻄﺔ‬ ‫‪‬‬
‫وﺳﻴﺘﻢ ﺗﺰوﻳﺪﻧﺎ ﺑﺎﻟﻔﻮاﺗﻴﺮ‪.‬‬

‫ﺗﻢ ﺑﻌﻮن اﷲ وﺗﻮﻓﻴﻘﻪ ﻋﻤﻠﻴﺔ اﻻﺳﺘﻼم واﻟﺘﺴﻠﻴﻢ ﺑﻤﻮﺟﺐ ﻫﺬا اﻟﻤﺤﻀﺮ ﻓﻲ ﻳﻮم ‪..........................‬‬

‫ﺑﺘﺎرﻳﺦ ‪1442 /.... /...‬ﻫـ ا‪ ،‬ﻟﻤﻮاﻓﻖ ‪2021/../...‬م‪ ،‬ﺑﻮاﺳﻄﺔ ﻛﻞ ﻣﻦ اﻻﺗﻴﺔ أﺳﻤﺎﺋﻬﻢ واﻟﻤﻮﻗﻌﻴﻦ ادﻧﺎه‪:‬‬

‫ﺷﺮﻛﺔ ﻓﻴﻮﻟﻜﺲ‬ ‫ﻣﺎﻟﻚ اﻟﻤﺤﻄﺔ او وﻛﻴﻠﻪ اﻟﺸﺮﻋﻲ‬

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