‫ﺍﻟﺗﺎﺭﻳﺦ‪.............../..../....:/‬ﻡ‪.

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‫ﻧﻣﻭﺫﺝ ﻁﻠﺏ ﺷﺭﺍء ﻋﻣﻠﺔ ﺃﺟﻧﺑﻳﺔ ﻟﻠﻣﻭﺍﻁﻧﻳﻥ ﻟﻸﻏﺭﺍﺽ ﺍﻟﺷﺧﺻﻳﺔ )ﻏﻳﺭ ﺗﺟﺎﺭﻳﺔ( ﺃﺭﺑﺎﺏ ﺍﻷﺳﺭ‬
‫ﺍﻟﺴﻴﺪ‪ /‬ﻣﺪﻳﺮ ﻓﺮﻉ ‪ /‬ﻭﻛﺎﻟﺔ‬

‫ﺍﻟﺠﻨﺲ‬ ‫ﺍﻟﺮﻗﻢ ﺍﻟﻮﻁﻨﻲ‬ ‫ﺍﻻﺳﻢ‬

‫ﻣﻜﺎﻥ ﺍﻹﻗﺎﻣﺔ‬ ‫ﺍﻟﺤﺎﻟﺔ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬ ‫ﻣﻜﺎﻥ ﻭﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ‬
‫ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‬ ‫ﻋﻨﻮﺍﻥ ﺍﻹﻗﺎﻣﺔ‬ ‫ﺍﺳﻢ ﺍﻷﻡ ﺑﺎﻟﻜﺎﻣﻞ‬

‫ﺍﻟﺒﺮﻳﺪ ﺍﻹﻟﻜﺘﺮﻭﻧﻲ‬ ‫ﺭﻗﻢ ﺟﻮﺍﺯ ﺍﻟﺴﻔﺮ ‪ /‬ﺑﻄﺎﻗﺔ ﺷﺨﺼﻴﺔ‬ ‫ﺭﻗﻢ ﺍﻟﺤﺴﺎﺏ ﺍﻟﺠﺎﺭﻱ ﺑﺎﻟﺪﻳﻨﺎﺭ‬
‫ﺍﻟﺠﻨﺲ‬ ‫ﺭﻗﻢ ﺣﺴﺎﺏ ﺑﺎﻟﻌﻤﻠﺔ ﺍﻷﺟﻨﺒﻴﺔ ﺃﻥ ﻭﺟﺪ‬ ‫ﺍﻟﻤﺒﻠﻎ ﺍﻟﻤﻄﻠﻮﺏ ﺷﺮﺍﺅﻩ ﺑﺎﻟﺪﻭﻻﺭ‬

‫ﻋﺪﺩ ﺃﻓﺮﺍﺩ ﺍﻷﺳﺮﺓ‬ ‫ﺭﻗﻢ ﺍﻟﻘﻴﺪ‬

‫ﺍﻟﺭﻗﻡ ﺍﻟﻭﻁﻧﻲ‬ ‫ﺍﻻﺳﻡ‬ ‫ﺕ‬
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‫ﻻ‬ ‫ﻧﻌﻡ‬ ‫ﻫﻝ ﺳﺑﻖ ﻟﻙ ﺍﻟﺣﺻﻭﻝ ﻋﻠﻰ ﺑﻁﺎﻗﺔ ﺇﻟﻛﺗﺭﻭﻧﻳﺔ ﺩﻭﻟﻳﺔ ﻣﻥ ﻣﺻﺭﻓﻧﺎ ﺃﻭ ﻣﻥ ﻣﺻﺎﺭﻑ ﺃﺧﺭﻱ‬

‫ﺁﻣﻝ ﻣﻧﻛﻡ ﺍﻟﻌﻣﻝ ﻋﻠﻰ‪:‬‬

‫ﺗﻧﻔﻳـﺫ ﺣـﻭﺍﻻﺕ ﺳﺭﻳﻌـﺔ‬ ‫ﺇﺻﺩﺍﺭ ﺑﻁﺎﻗﺔ ﻓﻳﺯﺍ ﻛﺎﺭﺩ‬

‫ﺍﻟﺗﻭﻗﻳﻊ‬ ‫‪............./..../....‬ﻡ‪.‬‬ ‫ﺍﻟﺗﺎﺭﻳﺦ‬ ‫ﺍﺳﻡ ﻣﻘﺩﻡ ﺍﻟﻁﻠﺏ‬

‫ﺍﻟﺑﺻﻣﺔ‬
‫ﻻﺳﺗﻌﻣﺎﻝ ﺍﻟﻔﺭﻉ ﺍﻟﻣﺻﺭﻓﻲ ﺍﻟﺫﻱ ﻁﺭﻓﻪ ﺻﺎﺣﺏ ﺍﻟﻁﻠﺏ‪:‬‬

‫ﺍﻋﺗﻣﺎﺩ ﻗﺳﻡ ﺍﻟﻣﺭﺍﺟﻌﺔ‪...............................................‬‬ ‫ﺍﺳﻡ ﺍﻟﻣﻭﻅﻑ ﺍﻟﻣﺧﺗﺹ‪.....................................‬‬

‫ﺍﻟﺗﻭﻗﻳﻊ ‪..............................................................‬‬ ‫ﺍﻟﺗﻭﻗﻳﻊ‪....................................................‬‬

‫ﺍﻟﺧﺗﻡ‪ / ................................... :‬ﺍﻟﺗﺎﺭﻳﺦ‪ ......../..../.... :‬ﻡ‪.‬‬ ‫ﺍﻟﺗﺎﺭﻳﺦ‪ .................../......./.......‬ﻡ‬

‫ﺍﻋﺗﻣﺎﺩ ﻣﺩﻳﺭ ﺍﻟﻔﺭﻉ ‪....................................‬‬ ‫‪.‬‬

‫ﺍﻟﺗﺎﺭﻳﺦ‪ ........../......./....... :‬ﻡ‪.‬‬

‫ﺍﻟﺧﺗﻡ‪......................................................... :‬‬