‫ﺒﺴﻡ ﺍﷲ ﺍﻝﺭﺤﻤﻥ ﺍﻝﺭﺤﻴﻡ‬

‫ﺍﻝﺴــــﻴﺩ ﺭﺌــــﻴﺱ ﻫﻴـــﺄﺓ ﺍﻝﺘﻘﺎﻋﺩ ﺍﻝﻭﻁﻨﻴﺔ ﺍﻝﻤﺤﺘــﺭﻡ‬

‫ﻡ‪ /‬ﻁﻠﺏ ﺤﻘﻭﻕ ﺘﻘﺎﻋﺩﻴﺔ‬

‫ﺃﻨﻲ ﺍﻝﻤﺘﻘﺎﻋﺩ ‪.........................................../‬‬

‫ﺒﺎﻝﻨﻅﺭ ﻻﺤﺎﻝﺘﻲ ﻋﻠﻰ ﺍﻝﺘﻘﺎﻋﺩ ﺒﺘﺎﺭﻴﺦ ‪............................../‬‬
‫ﺃﺭﺠﻭ ﺍﻝﺘﻔﻀل ﺒﺎﻝﻤﻭﺍﻓﻘﺔ ﻋﻠﻰ ﻤﻨــﺤــﻲ ﺍﻝﺤــﻘـــﻭﻕ ﺍﻝـﺘﻘـﺎﻋــﺩﻴﺔ‬
‫ﻋﻥ ﺨﺩﻤﺎﺘﻲ ﻓـﻲ ﻭﺯﺍﺭﺓ ‪ .........................‬ﻫﻴﺌـﺔ ‪...........................‬‬
‫ﺩﺍﺌﺭﺓ ‪....................‬‬
‫ﻭﺼﺭﻓﻪ ﻋﻠﻰ ﻤﺼﺭﻑ ) ﺍﻝﺭﺍﻓﺩﻴﻥ ‪ /‬ﺍﻝﺭﺸﻴﺩ ( ﻓﺭﻉ ‪.....................‬‬
‫‪ -‬ﻭﺍﻨﻲ ﺃﺘﻌﻬﺩ ﻝﻬﻴﺄﺓ ﺍﻝﺘﻘﺎﻋﺩ ﺍﻝﻭﻁﻨﻴﺔ ﺒﻌﺩﻡ ﺍﺴﺘﻼﻤﻲ ﺃﻱ ﺭﺍﺘﺏ ﻤﻥ ﺍﻝﺩﻭﻝـﺔ ﻓـﻲ ﺍﻝﻭﻗـﺕ‬
‫ﺍﻝﺤﺎﻀﺭ ﺴﻭﺍﺀ ﻜﺎﻥ ﻝﻘﺎﺀ ﻭﻅﻴﻔﺔ ﻋﻠﻰ ﺍﻝﻤﻼﻙ ﺍﻝﺩﺍﺌﻡ ﺍﻭ ﺍﻝﻤﺅﻗﺕ ﺍﻭ ﺒﻌﻘﺩ ﻭﺍﻥ ﺃﻗﻭﻡ ﺒﺈﺒﻼﻍ‬
‫ﻫﻴﺄﺓ ﺍﻝﺘﻘﺎﻋﺩ ﺍﻝﻭﻁﻨﻴﺔ ﻓﻭﺭ ﺃﻋﺎﺩﺓ ﺘﻌﻴﻴﻨﻲ ﻋﻠﻰ ﺍﻝﻤﻼﻙ ﺍﻝﺩﺍﺌﻡ ﺍﻭ ﺍﻝﻤﺅﻗﺕ ﺍﻭ ﺒﻌﻘﺩ ﻓﻲ ﺩﻭﺍﺌﺭ‬
‫ﺍﻝﺩﻭﻝﺔ ‪.‬‬
‫‪ -‬ﻭﺃﺘﻌﻬﺩ ﺒﺼﺤﺔ ﺍﻝﻤﺴﺘﻤﺴﻜﺎﺕ ﺍﻝﻤﻘﺩﻤﺔ ﻤﻥ ﻗﺒﻠﻲ ‪.‬‬
‫‪ -‬ﻭﺒﺨﻼﻑ ﺫﻝﻙ ﺃﺘﺤﻤل ﻜﺎﻓﺔ ﺍﻝﺘﺒﻌﺎﺕ ﺍﻝﻘﺎﻨﻭﻨﻴﺔ ﺍﻝﻤﺘﺭﺘﺒﺔ ﺒﺤﻘﻲ ﻭﻵﺠﻠﺔ ﻭﻗﻌﺕ ‪.‬‬
‫ﻋﻨﻭﺍﻥ ﺍﻝﺴﻜﻥ‬
‫ﺍﻝﻤﺤﺎﻓﻅﺔ ‪........................:‬‬
‫ﺍﻝﻤﻨﻁﻘﺔ ‪ .................. /‬ﺍﻝﺤﻲ‪................../‬‬
‫ﺩﺍﺭ ‪.............. /‬‬ ‫ﺯﻗﺎﻕ ‪........... /‬‬ ‫ﻤﺤﻠﺔ ‪........... /‬‬

‫ﺍﻝﺘﻭﻗﻴﻊ‬
‫ﺍﻻﺴﻡ ﺍﻝﺜﻼﺜﻲ ‪:‬‬
‫ﺍﻝﺘﺎﺭﻴﺦ ‪٢٠١١ / / :‬‬

‫ﺍﺴﻡ ﻭﺘﻭﻗﻴﻊ ﺍﻝﻤﻭﻅﻑ ﺍﻝﻤﺨﺘﺹ‪....................... /‬‬

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‫آ    ا  واردة  ‪ %*/‬ا  ا ‪ -.‬ا ‪ +),%‬و*)(‪ %‬ا ‪ &'%‬ا ‪$%‬و  "!     ذ ‬