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ﺧــﺎﺹ ﺑﺎﻟﻤﺘﻌﻠــــﻢ
NOM : BOUTAGRA ﺍﻟﻠﻘﺐ :ﺑﻮﺗﺎﻗﺮﺓ
PRENOM : AMIRA AMEL ﺍﻹﺳﻢ :ﺃﻣﻴﺮﺓ ﺃﻣﺎﻝ
ﺍﻟﻬﺎﺗﻒ 0782087167 : ﺗﺎﺭﻳﺦ ﻭ ﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ 2004-03-07 :ﺑــ :ﻋﻴﻦ ﺗﻤﻮﺷﻨﺖ
ﺍﻟﻌﻨﻮﺍﻥ :ﺭﻗﻢ 10ﻋﻤﺎﺭﺓ 01ﺣﻲ 50ﻣﺴﻜﻦ ﺷﻌﺒﺔ ﺍﻟﻠﺤﻢ
ﺍﻟﻮﻻﻳﺔ -ﺍﻟﺪﺍﺋﺮﺓ -ﺍﻟﺒﻠﺪﻳـــﺔ :ﻋﻴﻦ ﺗﻴﻤﻮﺷﻨﺖ -ﺍﻟﻤﺎﻟﺢ -ﺷﻌﺒﺔ ﺍﻟﻠﺤﻢ
ﻧﻮﻉ ﺍﻟﺪﺭﻭﺱ :ﻛﺘﺐ ﺍﻟﻤﺴﺘﻮﻯ ﻭ ﺍﻟﺸﻌﺒﺔ :ﺛﺎﻧﻴﺔ ﺛﺎﻧﻮﻱ ﻋﻠﻮﻡ ﺗﺠﺮﻳﺒﻴﺔ 214
ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ /ﺷ.ﺘ.ﻢ :ﻻ ﻧﻮﻉ ﺍﻟﻄﺎﻟﺐ :ﻣﺘﻌﻠﻢ ﻋﺎﺩﻱ ﻫﻞ ﺃﻧﺖ ﻣﺴﺠﻞ ﺑﺜﺎﻧﻮﻳﺔ ﺃﻭ ﻣﺘﻮﺳﻄﺔ :ﻻ
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ﻣﻼﺣﻈﺔ:
ﺗﺼﺮﻳﺢ ﺷﺮﻓﻲ ﻳﻤﻀﻰ ﻣﻦ ﻃﺮﻑ ﺍﻟﻤﻌﻨﻲ ﻭ ﻳﺼﺎﺩﻕ ﻋﻠﻴﻪ ﻓﻲ ﺍﻟﺒﻠﺪﻳﺔ ،ﻭ ﻳﻘﺺ ﻭ ﻳﻮﺩﻉ ﻓﻲ ﺍﻟﻤﺮﻛﺰ ﺍﻟﻮﻻﺋﻲ ﻣﻊ ﻣﻠﻒ ﺍﻟﺘﺴﺠﻴﻞ.
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ﺗﺼﺮﻳﺢ ﺷﺮﻓﻲ
ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺃﺳﻔﻠﻪ ﺍﻟﻤﺘﻌﻠﻢ :ﺑﻮﺗﺎﻗﺮﺓ ﺃﻣﻴﺮﺓ ﺃﻣﺎﻝ ﺑﺘﺎﺭﻳﺦ 2004-03-07ﺏ ﻋﻴﻦ ﺗﻤﻮﺷﻨﺖ
ﺃﺻﺮﺡ ﺑﺸﺮﻓﻲ ﺑﺄﻧﻨﻲ ﻗﺪ ﺃﻃﻠﻌﺖ ﻋﻠﻰ ﺑﻨﻮﺩ ﺍﻟﻨﻈﺎﻡ ﺍﻟﺪﺍﺧﻠﻲ ﻟﻤﺘﻌﻠﻤﻲ ﺍﻟﺪﻳﻮﺍﻥ ﺍﻟﻮﻃﻨﻲ ﻟﻠﺘﻌﻠﻴﻢ ﻭ ﺍﻟﺘﻜﻮﻳﻦ ﻋﻦ ﺑﻌﺪ ﺍﻟﺼﺎﺩﺭ ﻓﻲ ﺍﻟﺴﻨﺔ ﺍﻟﺪﺭﺍﺳﻴﺔ 2024/2023
)ﺳﺒﺘﻤﺒﺮ (2023ﻭ ﺃﻟﺘﺰﻡ ﺑﺘﻄﺒﻴﻖ ﻣﺎ ﻭﺭﺩ ﻓﻴﻪ ﻣﻦ ﺗﻌﻠﻴﻤﺎﺕ ﻭ ﺗﻮﺟﻴﻬﺎﺕ
-ﺃﻭﺍﻓﻖ ﻋﻠﻰ ﺃﻥ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﺘﻲ ﺳﻴﺘﻢ ﺟﻤﻌﻬﺎ ﻓﻲ ﺍﺳﺘﻤﺎﺭﺓ ﻃﻠﺐ ﺍﻟﺘﺴﺠﻴﻞ ﺳﺘﺴﺘﺨﺪﻡ ﻣﻦ ﻃﺮﻑ ﺍﻟﺪﻳﻮﺍﻥ ﺍﻟﻮﻃﻨﻲ ﻟﻠﺘﻌﻠﻴﻢ ﻭ ﺍﻟﺘﻜﻮﻳﻦ ﻋﻦ ﺑﻌﺪ ﻣﻦ ﺃﺟﻞ ﺍﻧﺸﺎﺀ ﺍﻟﻤﻠﻒ
ﺍﻟﺒﻴﺪﺍﻏﻮﺟﻲ ﺍﻟﺨﺎﺹ ﺑﻲ ،ﻛﻤﺎ ﻳﺘﻢ ﺍﻹﺣﺘﻔﺎﻅ ﺑﻬﺎ ﻭ ﺍﺳﺘﻐﻼﻟﻬﺎ/ﻣﻌﺎﻟﺠﺘﻬﺎ ﻃﻴﻠﺔ ﻣﺪﺓ ﻣﺘﺎﺑﻌﺘﻲ ﻟﻠﺪﺭﺍﺳﺔ ﺑﺎﻟﺪﻳﻮﺍﻥ ،ﻭﻓﻘﺎ ﻟﻠﻘﺎﻧﻮﻥ 18-07ﺍﻟﻤؤﺭﺥ ﻓﻲ 10ﻳﻮﻧﻴﻮ
2018ﺍﻟﻤﺘﻌﻠﻖ ﺑﺤﻤﺎﻳﺔ ﺍﻷﺷﺨﺎﺹ ﺍﻟﻄﺒﻴﻌﻴﻴﻦ ﻓﻲ ﻣﺠﺎﻝ ﻣﻌﺎﻟﺠﺔ ﺍﻟﻤﻌﻄﻴﺎﺕ ﺫﺍﺕ ﺍﻟﻄﺎﺑﻊ ﺍﻟﺸﺨﺼﻲ .
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ﻓـﻲ ﺇﻃـﺎﺭ ﺍﻹﺟﺮﺍءﺍﺕ ﺍﻟﻘﺎﻧﻮﻧﻴﺔ ﺍﻟﻤﻌﻤﻮﻝ ﺑﻬﺎ ،ﻭﻋﻤﻼ ﺑﺎﻟﻤﻨﺸﻮﺭ ﺭﻗﻢ 444ﺍﻟﻤؤﺭﺥ ﻓﻲ 29ﺟﻮﻳﻠﻴﺔ ، 2000ﻭ ﺍﻟﺼﺎﺩﺭ ﻋﻦ ﻣﺼﺎﻟﺢ ﺭﺋﻴﺲ
ﺍﻟﺤﻜﻮﻣﺔ ،ﺍﻟﻤﺪﻳﺮﻳﺔ ﺍﻟﻌﺎﻣﺔ ﻟﻠﻮﻇﻴﻒ ﺍﻟﻌﻤﻮﻣﻲ ،ﻭﺍﻟﻤﺘﻌﻠﻖ ﺑﺘﻮﺛﻴﻖ ﺍﻟﻤؤﻫﻼﺕ ﻭﺍﻟﺸﻬﺎﺩﺍﺕ ﻭ ﺣﻔﺎﻇﺎ ﻋﻠﻰ ﻣﺼﺪﺍﻗﻴﺔ ﻣؤﺳﺴﺎﺗﻨﺎ ﺍﻟﺘﺮﺑﻮﻳﺔ
ﻭﺍﻟﺘﻌﻠﻴﻤﻴﺔ ،ﻧﻄﻠﺐ ﻣﻦ ﺳﻴﺎﺩﺗﻜﻢ ﺍﻟﻤﺤﺘﺮﻣﺔ ﺇﻓﺎﺩﺗﻨﺎ ﺑﻤﺪﻯ ﺻﺤﺔ ﺍﻟﺸﻬﺎﺩﺓ ﺍﻟﻤﺪﺭﺳﻴﺔ ﺍﻟﻤﻘﺪﻣﺔ ﻣﻦ ﻃﺮﻑ .
ﺍﻟﻤﺘﻌﻠﻢ )ﺓ( :ﺑﻮﺗﺎﻗﺮﺓ ﺃﻣﻴﺮﺓ ﺃﻣﺎﻝ
ﺗﺎﺭﻳﺦ ﻭ ﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ 2004-03-07 :ﺑــ :ﻋﻴﻦ ﺗﻤﻮﺷﻨﺖ
ﺍﻟﺴﻨﺔ ﺍﻟﺪﺭﺍﺳﻴﺔ .................................... : ﻣﺴﺠﻞ )ﺓ( ﻓﻲ ﺍﻟﻤﺴﺘﻮﻯ .................................... :
ﺍﺳﻢ ﻭ ﻟﻘﺐ ﻭﺧﺘﻢ ﻭ ﺇﻣﻀﺎﺀ ﻣﺪﻳﺮ )ﺓ( ﺍﻟﻤﺮﻛﺰ ﺍﻟﻮﻻﺋﻲ
ﺍﻟﻤﺘﻌﻠﻢ )ﺓ( ﺍﻟﻤﺬﻛﻮﺭ ﺃﻋﻼﻩ ﻣﺴﺠﻞ )ﺓ( ﺑﺎﻟﺴﺠﻴﻼﺕ ﺍﻟﺮﺳﻤﻴﺔ ﻟﻤؤﺳﺴﺘﻨﺎ ﺗﺤﺖ ﺭﻗﻢ ............... :
ﻟﻠﺴﻨﺔ ﺍﻟﺪﺭﺍﺳﻴﺔ .............. :ﻟﻤﺴﺘﻮﻯ . ...............................
ﺍﻟﻤﻌﺪﻝ ﺍﻟﻌﺎﻡ ﺍﻟﺴﻨﻮﻱ .........:ﺗﺎﺭﻳﺦ ﺍﻟﺨﺮﻭﺝ ...................:ﻭ ﻋﻠﻴﻪ ﺍﻟﺸﻬﺎﺩﺓ ﺍﻟﻤﺪﺭﺳﻴﺔ ﻟﻠﻤﻌﻨﻲ )ﺓ( .............. :
ﺍﻟﻤﺘﻌﻠﻢ )ﺓ( ﺍﻟﻤﺬﻛﻮﺭ ﺃﻋﻼﻩ ﻏﻴﺮ ﻣﺴﺠﻞ )ﺓ( ﺑﺎﻟﺴﺠﻴﻼﺕ ﺍﻟﺮﺳﻤﻴﺔ ﻟﻤؤﺳﺴﺘﻨﺎ ﻭ ﺷﻬﺎﺩﺓ ﻣﺪﺭﺳﻴﺔ ...............
ﺃﻛﺘﺐ ﻓﻲ ﺍﻹﻃﺎﺭ ﺍﻟﺘﺎﻟﻲ :ﺷﻬﺎﺩﺓ ﻣﺪﺭﺳﻴﺔ ﺻﺎﺩﻗﺔ ﺃﻭ ﺷﻬﺎﺩﺓ ﻣﺪﺭﺳﻴﺔ ﻏﻴﺮ ﺻﺎﺩﻗﺔ
-ﺑﻌﺪ ﺍﻟﺨﺘﻢ ﻭ ﺍﻟﻤﺼﺎﺩﻗﺔ ﻋﻠﻰ ﻫﺬﻩ ﺍﻟﻮﺛﻴﻘﺔ ﺗﺮﺟﻊ ﻛﺎﻣﻠﺔ ﺩﻭﻥ ﻗﺼﻬﺎ .