‫ﺑﺴﻤﻪ ﺗﻌﺎﻟﯽ‬

‫ﺗـﺎرﯾــﺦ ‪............................................................... :‬‬

‫ﺷﻤﺎره ﭘﺮوﻧﺪه ‪........................................ :‬‬

‫ﺷﻤﺎره ﺑﺎﯾﮕﺎﻧﯽ ‪........................................ :‬‬

‫ﺻﻔﺤﻪ اول‬ ‫ﺷﮑﻮاﯾﯿﻪ‬

‫ﻣﺬﻫﺐ‬ ‫ﺗﺎﺑﻌﯿﺖ‬ ‫وﺿﻌﯿﺖﺗﺄﻫﻞ‬ ‫ﻣﯿﺰان ﺗﺤﺼﯿﻼت‬ ‫ﺷﻐﻞ‬ ‫ﺗﺎرﯾﺦ ﺗﻮﻟﺪ‬ ‫ﻧﺎم ﭘﺪر‬ ‫ﻧﺎم و ﻧﺎم ﺧﺎﻧﻮادﮔﯽ‬

‫ﭘﯿﺎم ﻧﮕﺎر )اﯾﻤﯿﻞ(‬ ‫ﺗﻠﻔﻦ ﻫﻤﺮاه‬ ‫ﺗﻠﻔﻦ ﺛﺎﺑﺖ )ﺑﺎﮐﺪ ﺷﻬﺮ(‬ ‫ﺷﻤﺎره ﻣﻠﯽ‬ ‫ﻣﺤﻞﺻﺪور‬ ‫ﺷﻤﺎره ﺷﻨﺎﺳﻨﺎﻣﻪ‬

‫ﺷــﺎﮐﯽ‬
‫ﻧﺸﺎﻧﯽ دﻗﯿﻖ ‪:‬‬
‫ﮐﺪ ﭘﺴﺘﯽ‪:‬‬
‫ﭘﯿﺎم ﻧﮕﺎر )اﯾﻤﯿﻞ(‬ ‫ﺗﻠﻔﻦ ﻫﻤﺮاه‬ ‫ﺗﻠﻔﻦ ﺛﺎﺑﺖ )ﺑﺎﮐﺪ ﺷﻬﺮ(‬ ‫ﺷﻤﺎره ﻣﻠﯽ‬ ‫ﻧﺎم ﭘﺪر‬ ‫ﻧﺎم و ﻧﺎم ﺧﺎﻧﻮادﮔﯽ‬

‫وﮐﯿﻞ‪/‬ﻧﻤﺎﯾﻨﺪهﺷﺎﮐﯽ‬
‫ﺷﻤﺎره ﭘﺮواﻧﻪ وﮐﺎﻟﺖ ﯾﺎ ﻧﺎﻣﻪ ‪:‬‬ ‫ﺳﻤﺖ‪:‬‬

‫ﻧﺸﺎﻧﯽ دﻗﯿﻖ ‪:‬‬

‫ﮐﺪ ﭘﺴﺘﯽ‪:‬‬
‫ﻧﺸﺎﻧﯽ‪:‬‬ ‫ﺷﻤﺎره ﺗﻠﻔﻦ‪:‬‬ ‫ﻧﺎم‪:‬‬

‫ﻣﺸﺘﮑﯽ ﻋﻨﻪ‪ /‬ﻣﻈﻨﻮن‬

‫ﻧﺎم ﭘﺪر‪:‬‬

‫ﻣﺸﺨﺼﺎت و ﻧﺸﺎﻧﯽ‬
‫ﻧﺎم ﺧﺎﻧﻮادﮔﯽ‪:‬‬

‫ﻣﻮﺿﻮع ﺷﮑﺎﯾﺖ‪:‬‬

‫ﺑﻪ ﺷﺮح ﭘﯿﻮﺳﺖ‬

‫ﺷﮑﺎﯾﺖ‬

‫ﻣﯿﺰان ﺿﺮر و زﯾﺎن ﻣﻮرد ﻣﻄﺎﻟﺒﻪ‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎرﯾﺦ وﻗﻮع ﺟﺮم‪:‬‬ ‫ﻣﺤﻞ وﻗﻮع ﺟﺮم‪:‬‬
‫ﺳﺎﻋﺖ ‪:‬‬
‫اﻣﻀﺎء ﯾﺎ اﺛﺮ اﻧﮕﺸﺖ ﺷﺎﮐﯽ‬ ‫ﻣﺸﺨﺼﺎت و ﻧﺸﺎﻧﯽ دﻗﯿﻖ ﺷﻬﻮد و ﻣﻄﻠﻌﺎن ‪ /‬ﺳﺎﯾﺮ ادﻟﻪ‬
‫ادﻟﻪ وﻗﻮع ﺟﺮم‬
‫ارﺟﺎع‬

‫ﻓﺮم ﺷﻤﺎره ‪ 1393/24/2201/2224‬اداره ﮐﻞ ﺑﻬﺒﻮد روشﻫﺎ و ﻓﺮآﯾﻨﺪﻫﺎي ﻗﻮه ﻗﻀﺎﯾﯿﻪ‬ ‫ﺗﻮﺟﻪ‪ :1‬ﺷﮑﺎﯾﺖ در ﺻﻔﺤﻪ دوم ﻧﻮﺷﺘﻪ ﺷﻮد‪.‬‬
‫ﺗﻮﺟﻪ ‪ :2‬درﺻﻮرت ﺗﻌﺪد ﺷﺎﮐﯽ‪ ،‬ﻣﺸﺘﮑﯽ ﻋﻨﻪ و ﺷﺎﻫﺪ‪ ،‬ﻧﺎم آﻧﻬﺎ در اداﻣﻪ ﺷﺮح ﺷﮑﻮاﯾﯿﻪ درج ﺷﻮد‪.‬‬
 ‫ﺑﺴﻤﻪ ﺗﻌﺎﻟﯽ‬
‫ﺗـﺎرﯾــﺦ ‪............................................................... :‬‬

‫ﺷﻤﺎره ﭘﺮوﻧﺪه ‪........................................ :‬‬

‫ﺷﻤﺎره ﺑﺎﯾﮕﺎﻧﯽ ‪........................................ :‬‬

‫ﺻﻔﺤﻪ دوم‬ ‫ﺷﺮح ﺷﮑﺎﯾﺖ‬

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‫ﻧﺎم و ﻧﺎم ﺧﺎﻧﻮادﮔﯽ‪ ،‬ﺷﻤﺎره ﻣﻠﯽ و اﻣﻀﺎء ﯾﺎ اﺛﺮاﻧﮕﺸﺖ ﺷﺎﮐﯽ‬

‫ﻓﺮم ﺷﻤﺎره ‪ 1393/24/2201/2224‬اداره ﮐﻞ ﺑﻬﺒﻮد روشﻫﺎ و ﻓﺮآﯾﻨﺪﻫﺎي ﻗﻮه ﻗﻀﺎﯾﯿﻪ‬