‫‪Critical Infrastructure & Coastal Protection Authority‬‬ ‫ﺟﻬﺎﺯ ﺣﻤﺎﻳﺔ ﺍﻟﻤﻨﺸﺂﺕ ﺍﻟﺤﻴﻮﻳﺔ ﻭﺍﻟﺴﻮﺍﺣﻞ‬

‫‪Infrastructure Permt’s Department‬‬ ‫ﺷﻌﺒﺔ ﺗﺼﺎﺭﻳﺢ ﺍﻟﻤﻨﺸﺂﺕ ﺍﻟﺤﻴﻮﻳﺔ‬

‫*‬
‫ﻭﺛـﻴـﻘـــﺔ ﺗــﻌــــﺎﺭﻑ ‪Introduction Form‬‬

‫ﻧﻤــﻮﺫﺝ ﺭﻗـــﻢ )‪(7‬‬

‫‪Applicant’s Details‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺸﺨﺺ‬
‫‪Full Name‬‬ ‫ﺍﻹﺳـﻢ ﺑـﺎﻟﻜــﺎﻣﻞ‬
‫‪Nickname‬‬ ‫‪ Surname‬ﺇﺳـﻢ ﺍﻟـﺸـﻬــﺮﺓ‬ ‫ﺇﺳـــﻢ ﺍﻟـﻌــﺎﺋـﻠـﺔ‬
‫‪Previous Nationality‬‬ ‫‪ Nationality‬ﺍﻟﺠﻨﺴﻴﺔ ﺍﻟﺴﺎﺑﻘﺔ‬ ‫ﺍﻟﺠﻨﺴﻴـﺔ ﺍﻟـﺤﺎﻟﻴﺔ‬
‫‪Place Of Birth‬‬ ‫‪ Religion /Doctrine‬ﻣـﻜـﺎﻥ ﺍﻟـﻤـﻴﻼﺩ‬ ‫ﺍﻟﺪﻳـﺎﻧـﺔ‪/‬ﺍﻟﻤﺬﻫﺐ‬
‫‪Date Of Entry‬‬ ‫‪ Date Of Birth‬ﺗــﺎﺭﻳـﺦ ﺍﻟـﺪﺧﻮﻝ‬ ‫ﺗــــﺎﺭﻳﺦ ﺍﻟـﻤﻴـﻼﺩ‬
‫ﺍﻟﺼــــﻮﺭﺓ ‪Photograph‬‬
‫‪(6 X 4) cm‬‬ ‫‪Port of Entry‬‬ ‫ﻣـﺮﻛــﺰ ﺍﻟـﺪﺧﻮﻝ‬ ‫‪Sponsor’s Name‬‬ ‫ﺍﻟﻜﻔﻴﻞ ﻋﻨﺪ ﺍﻟﺪﺧﻮﻝ‬

‫‪Office Tel.‬‬ ‫ﻫﺎﺗﻒ ﺍﻟﻌﻤﻞ‬ ‫‪Current Sponsor‬‬ ‫ﺍﻟـﻜﻔﻴـﻞ ﺍﻟﺤــﺎﻟـﻲ‬

‫‪Occupation‬‬ ‫‪ Work Location‬ﺍﻟـــﻤـﻬــﻨــﺔ‬ ‫ﻣـﻜــــﺎﻥ ﺍﻟـﻌـﻤـﻞ‬
‫‪Bank‬‬ ‫‪ Salary‬ﺍﻟﺒــﻨـــــــﻚ‬ ‫ﺍﻟــــﺮﺍﺗـــﺐ‬

‫‪Place of Issue‬‬ ‫‪ Passport No.‬ﻣﻜـﺎﻥ ﺍﻹﺻـﺪﺍﺭ‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﺯ‪/‬ﺍﻟﻮﺛﻴﻘﺔ‬

‫‪Expiry Date‬‬ ‫‪ Date Of Issue‬ﺗـﺎﺭﻳـﺦ ﺍﻹﻧﺘﻬـﺎﺀ‬ ‫ﺗـــﺎﺭﻳـﺦ ﺍﻹﺻـﺪﺍﺭ‬
‫‪Place Of Issue‬‬ ‫‪ Residence No.‬ﻣـﻜـﺎﻥ ﺍﻹﺻـﺪﺍﺭ‬ ‫ﺭﻗـــــﻢ ﺍﻹﻗـــﺎﻣـﺔ‬
‫‪Expiry Date‬‬ ‫‪ Date Of Issue‬ﺗــﺎﺭﻳـﺦ ﺍﻹﻧﺘﻬﺎﺀ‬ ‫ﺗــﺎﺭﻳـﺦ ﺍﻹﺻــﺪﺍﺭ‬

‫‪Education‬‬ ‫ﺍﻟـﻤﺆﻫﻞ ﺍﻟﺪﺭﺍﺳﻲ‬

‫‪College/University‬‬ ‫‪ Graduation‬ﺍﻟﻤﺪﺭﺳﺔ‪/‬ﺍﻟﺠﺎﻣﻌﺔ‬ ‫ﺗـﺎﺭﻳــﺦ ﺍﻟـﺘـﺨــﺮﺝ‬
‫‪Place Of Issue‬‬ ‫‪ Residence No.‬ﻣـﻜـﺎﻥ ﺍﻹﺻــﺪﺍﺭ‬ ‫ﺭﻗـــﻢ ﺍﻹﻗــــــﺎﻣﺔ‬
‫‪Country‬‬ ‫‪ Languages‬ﺍﻟــﺪﻭﻟــﺔ‬ ‫ﺍﻟﻠــﻐــــــﺎﺕ‬

‫‪Spouse Name‬‬ ‫‪ Martial Status‬ﺇﺳﻢ ﺍﻟﺰﻭﺝ‪/‬ﺍﻟﺰﻭﺟﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻹﺟﺘﻤﺎﻋﻴﺔ‬

‫‪Place Of Birth‬‬ ‫‪ Nationality‬ﻣـﻜــﺎﻥ ﺍﻟـﻤﻴﻼﺩ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪Employer‬‬ ‫‪ Occupation‬ﻣﻜﺎﻥ ﺍﻟﻌﻤﻞ‬ ‫ﺍﻟﻤﻬﻨﺔ‬ ‫‪Date Of Birth‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬

‫‪Children Names‬‬ ‫ﺃﺳﻤـﺎﺀ ﺍﻷﺑﻨـﺎﺀ‬

‫‪5‬‬ ‫‪1‬‬
‫‪6‬‬ ‫‪2‬‬
‫‪7‬‬ ‫‪3‬‬
‫‪8‬‬ ‫‪4‬‬

‫‪Nationality‬‬ ‫‪ Father’s Name‬ﺍﻟـﺠــﻨـﺴــــــﻴـﺔ‬ ‫ﺇﺳـــــﻢ ﺍﻷﺏ‬

‫‪Date Of Bith‬‬ ‫‪ Place Of Birth‬ﺗـﺎﺭﻳــﺦ ﺍﻟـﻤﻴﻼﺩ‬ ‫ﻣـﻜــﺎﻥ ﺍﻟـﻤـﻴـﻼﺩ‬
‫‪Occupation‬‬ ‫‪ Employer‬ﺍﻟـﻤــﻬــﻨــﺔ‬ ‫ﻣـﻜــﺎﻥ ﺍﻟــﻌـﻤـﻞ‬
‫‪Nationality‬‬ ‫‪ Mother’s Name‬ﺍﻟـﺠـﻨـﺴـﻴﺔ‬ ‫ﺇﺳــــﻢ ﺍﻷﻡ‬

‫‪Date Of Bith‬‬ ‫‪ Place Of Birth‬ﺗـﺎﺭﻳــﺦ ﺍﻟـﻤﻴﻼﺩ‬ ‫ﻣـﻜـﺎﻥ ﺍﻟــﻤﻴــﻼﺩ‬

‫‪Occupation‬‬ ‫‪ Employer‬ﺍﻟـﻤــﻬــﻨــﺔ‬ ‫ﻣـﻜـﺎﻥ ﺍﻟـــﻌــﻤـﻞ‬

‫‪* The document should be hand written in Arabic for Arabs‬‬ ‫* ﻛـﺘــﺎﺑﺔ ﺍﻟـﻮﺛﻴـﻘـﺔ ﺑــﺨـﻂ ﺍﻟـﻴـﺪ ﺑـﺎﻟﻨﺴﺒﺔ ﻟﻠــﻌــﺮﺏ ﺃﻭ ﻣــﻦ ﺃﺻــﻞ‬
‫‪nationals & English typing for other nationalities.‬‬ ‫ﻋـﺮﺑـﻲ ﺃﻣـﺎ ﺑـﺎﻟﻨﺴﺒﺔ ﻟﻸﺟـﺎﻧـﺐ ﻃﺒـﺎﻋـﺔ ﺍﻟﻮﺛﻴﻘﺔ ﺑﺎﻟﻠﻐﺔ ﺍﻹﻧﺠﻠﻴﺰﻳﺔ‪.‬‬
 ‫‪Relatives‬‬ ‫ﺍﻷﻗﺎﺭﺏ‬
‫‪Employer‬‬ ‫ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ ‫‪Nationality‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬ ‫‪Name‬‬ ‫ﺍﻹﺳــﻢ‬ ‫‪#‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬

‫‪Friends‬‬ ‫ﺍﻷﺻﺪﻗﺎﺀ‬
‫‪Employer‬‬ ‫ﺟﻬﺔ ﺍﻟﻌﻤﻞ‬ ‫‪Nationality‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬ ‫‪Name‬‬ ‫ﺍﻹﺳــﻢ‬ ‫‪#‬‬
‫‪1‬‬
‫‪2‬‬
‫‪3‬‬

‫‪Residence Address‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﺴﻜﻦ‬

‫‪Street‬‬ ‫‪ Location‬ﺍﻟــﺸــــﺎﺭﻉ‬ ‫ﺍﻟﻤﻨـﻄــﻘــﺔ‬
‫‪Bldg. No.‬‬ ‫‪ Landlord‬ﺭﻗﻢ ﺍﻟﻤﻨﺰﻝ‪/‬ﺍﻟﺒﻨﺎﻳﺔ‬ ‫ﺇﺳﻢ ﺍﻟﻤﺎﻟﻚ‬
‫‪Flat No.‬‬ ‫‪ Floor‬ﺭﻗﻢ ﺍﻟﺸﻘﺔ‬ ‫ﺍﻟـﻄـــﺎﺑــﻖ‬
‫‪Mobile No.‬‬ ‫‪ Telephone‬ﺍﻟﻬﺎﺗﻒ ﺍﻟﻤﺘﺤﺮﻙ‬ ‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬

‫‪P.O.Box‬‬ ‫‪ Pager‬ﺻﻨـﺪﻭﻕ ﺍﻟـﺒـﺮﻳﺪ‬ ‫ﺭﻗﻢ ﺍﻟﻨﺪﺍﺀ ﺍﻟﻌﺎﻡ‬

‫ﺍﻷﻋﻤﺎﻝ ﺍﻟﺘﻲ ﻣﺎﺭﺳﺘﻬﺎ ﺩﺍﺧﻞ ﺍﻟﺪﻭﻟﺔ ‪Previous Occupation in UAE‬‬

‫‪3‬‬ ‫‪1‬‬
‫‪4‬‬ ‫‪2‬‬

‫‪Countries you visited‬‬ ‫ﺍﻟﺪﻭﻝ ﺍﻟﺘﻲ ﺳﺒﻖ ﻟﻚ ﺯﻳﺎﺭﺗﻬﺎ‬

‫‪4‬‬ ‫‪1‬‬
‫‪5‬‬ ‫‪2‬‬
‫‪6‬‬ ‫‪3‬‬

‫‪Countries you worked with‬‬ ‫ﺍﻟﺪﻭﻝ ﺍﻟﺘﻲ ﺳﺒﻖ ﻟﻚ ﺍﻟﻌﻤﻞ ﺑﻬﺎ‬

‫‪4‬‬ ‫‪1‬‬
‫‪5‬‬ ‫‪2‬‬
‫‪6‬‬ ‫‪3‬‬

‫‪Car Information‬‬ ‫ﺑﻴﺎﻧﺎﺕ ﺍﻟﻤﺮﻛﺒﺔ‬

‫‪Place Of Regis.‬‬ ‫‪ Car Brand‬ﺟﻬﺔ ﺍﻟﺘﺮﺧﻴﺺ‬ ‫ﻧﻮﻉ ﺍﻟﻤﺮﻛﺒﺔ‬
‫‪Plate Color‬‬ ‫‪ Plate No.‬ﻟــــﻮﻥ ﺍﻟﻠﻮﺣﺔ‬ ‫ﺭﻗﻢ ﺍﻟﻠﻮﺣﺔ‬
‫‪Place Of Issue‬‬ ‫‪ License No.‬ﻣﻜﺎﻥ ﺍﻹﺻﺪﺍﺭ‬ ‫ﺭﻗﻢ ﺭﺧﺼﺔ ﺍﻟﻘﻴﺎﺩﺓ‬
‫‪Expiry Date‬‬ ‫‪ Date Of Issue‬ﺍﻟﻬﺎﺗﻒ ﺍﻟﻤﺘﺤﺮﻙ‬ ‫ﺗﺎﺭﻳﺦ ﺍﻹﺻﺪﺍﺭ‬

‫‪Have you served in the Military Service:‬‬ ‫‪Yes‬‬ ‫‪No‬‬ ‫ﻻ‬ ‫ﻧﻌﻢ‬ ‫ﻫﻞ ﺳﺒﻖ ﻟﻚ ﺍﻟﻌﻤﻞ ﻓﻲ ﺍﻟﻤﺠﺎﻝ ﺍﻟﻌﺴﻜﺮﻱ‪:‬‬
‫‪Level Of Service‬‬ ‫‪ Country‬ﻧــــﻮﻉ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺇﺳﻢ ﺍﻟﺪﻭﻟﺔ‬
‫‪Date Of Service‬‬ ‫‪ Rank‬ﻣــــﺪﺓ ﺍﻟﺨﺪﻣﺔ‬ ‫ﺍﻟﺮﺗﺒﺔ‬

‫‪I, Undersigned certify that all the above statement are‬‬ ‫ﺃﺗﻌﻬﺪ ﺃﻧﺎ ﺍﻟﻤﻮﻗﻊ ﺃﺩﻧﺎﻩ ﺑﺄﻥ ﺍﻟﺒﻴﺎﻧﺎﺕ ﺍﻟﻮﺍﺭﺩﺓ ﺑﻬﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ‬
‫‪correct & complete.‬‬ ‫ﺻﺤﻴﺤﺔ ﻭﻛﺎﻣﻠﺔ‪.‬‬

‫‪Date‬‬ ‫ﺍﻟﺘﺎﺭﻳﺦ‬ ‫‪Signature‬‬ ‫ﺍﻟﺘﻮﻗﻴﻊ‬ ‫‪Name‬‬ ‫ﺍﻹﺳـــﻢ‬

‫‪Include the following with this statement:‬‬ ‫ﺍﻟﻤﺮﻓﻘﺎﺕ ﺍﻟﻤﻄﻠﻮﺑﺔ‪:‬‬

‫‪Photographs & Passport Copy.‬‬ ‫ﺻﻮﺭ ﺷﻤﺴﻴﺔ ﻭ ﺻﻮﺭﺓ ﺟﻮﺍﺯ ﺍﻟﺴﻔﺮ‪.‬‬