‫اﺳﺘﻤﺎرات اﻟﺨﺪﻣﺎت اﻟﻘﻨﺼﻠﯿﮫ‬ ‫‪https://www.egypt-nyc.

com/agencies-forms#first‬‬

‫اﻟﻘﻨﺼﻠﻴﺔ اﻟﻌﺎﻣﺔ ﻟﺠﻤﻬﻮر ﻳﺔ ﻣ‪ 2‬اﻟﻌﺮﺑﻴﻪ ﻓﻰ ﻧﻴﻮﻳﻮرك‬

‫ﺗﻮﻛﻴﻞ ﺧﺎص ﻓﻰ اﻟﻄﻼق‬

‫‪/‬‬ ‫‪/‬‬ ‫اﻟﻤﻮاﻓﻖ ‪:‬‬ ‫اﻧﻪ ﻓﻰ ﻳﻮم ‪:‬‬

‫ﻓﻲ ﺗﻤﺎم اﻟﺴﺎﻋﺔ ‪:‬‬ ‫أﻣﺎﻣﻨﺎ ﻧﺤﻦ ‪:‬‬

‫ﺣ"‬

‫إﺳﻢ اﻟﻤﻮﻛﻞ ‪:‬‬

‫اﻟﻤﻬﻨﺔ ‪:‬‬ ‫اﻟﺠﻨﺴﻴﺔ ‪:‬‬

‫ﺟﻬﺔ اﻻﺻﺪار ‪:‬‬ ‫اﻟﺜﺎﺑﺖ اﻟﺸﺨﺼﻴﺔ ﺑﻤﻮﺟﺐ)رﻗﻢ ﻗﻮﻣﻰ ‪ /‬ﺟﻮاز ﺳﻔﺮ ( ‪:‬‬

‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎر ﻳﺦ اﻟﻤﻴﻼد ‪:‬‬ ‫ﻣﺤﻞ اﻟﻤﻴﻼد ‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎر ﻳﺦ اﻻﺻﺪار ‪:‬‬

‫اﻟﻤﻘﻴﻢ ﻓﻲ ‪:‬‬

‫و ﻗﺮر إﻧﻪ وﻛﻞ ﻋﻨﻪ‬

‫اﻟﺠﻨﺴﻴﺔ ‪:‬‬ ‫إﺳﻢ اﻟﻮﻛﻴﻞ ‪:‬‬

‫اﻟﻤﻘﻴﻢ ﻓﻲ ‪:‬‬ ‫اﻟﻤﻬﻨﺔ ‪:‬‬

‫وذﻟﻚ ﻓﻲ اﺗﺨﺎذي ﻛﺎﻓﺔ اﻻﺟﺮات اﻟﻼزﻣﺔ ﻟﺰواﺟﻲ ﻣﻦ ‪:‬‬

‫اﻟﻤﻘﻴﻢ ‪/‬اﻟﻤﻘﻴﻤﺔ ﻓﻲ ‪:‬‬ ‫اﺑﻦ‪/‬اﺑﻨﺔ )اﺳﻢ اﻻم (‪:‬‬

‫واﻟﺘﻮﻗﻴﻊ ﻧﻴﺎﺑًﺔ ﻋ‪ /‬ﻋ‪ 0‬ﻋﻘﺪ اﻟﻄﻼق وإﺳﺘﻼﻣﻪ ﻧﻴﺎﺑًﺔ ﻋ‪./‬‬

‫وﺑﻢ ذﻛﺮ ﺗﺤﺮر ﻫﺬا اﻟﺘﻮﻛﻴﻞ وﺗﻢ اﻟﺘﻮﻗﻴﻊ ﻋﻠﻴﻪ ﻣﻦ اﻟﻤﻮﻛﻞ ﺑﻌﺪ ﺗﻼوﺗﻪ ﻋﻠﻴﻪ ‪.‬‬

‫‪1 of 2‬‬ ‫‪8/4/23, 19:58‬‬

‫اﺳﺘﻤﺎرات اﻟﺨﺪﻣﺎت اﻟﻘﻨﺼﻠﯿﮫ‬ ‫‪https://www.egypt-nyc.com/agencies-forms#first‬‬

‫ﺗﻢ اﻟﺘﻮﻗﻴﻊ أﻣﺎﻣﻰ ‪:‬‬ ‫اﻟﻤﻮﻛﻞ ‪:‬‬

‫اﻟﻤﻮﺛﻖ ‪:‬‬ ‫اﻻﺳﻢ ‪:‬‬

‫اﻟﺘﻮﻗﻴﻊ ‪:‬‬ ‫اﻟﺘﻮﻗﻴﻊ ‪:‬‬

‫‪2 of 2‬‬ ‫‪8/4/23, 19:58‬‬