‫اﻟﺠﻤﮭﻮرﯾﺔ اﻟﺘﻮﻧﺴﯿﺔ‬

‫وزارة اﻟﺼﺤﺔ‬
‫اﻟﮭﯿﻜﻞ ‪ :‬وﺣﺪة اﻟﺼﯿﺪﻟﺔ واﻟﺪواء‬
‫طﻠﺐ رﺧﺼﺔ اﺳﺘﻐﻼل ﺻﯿﺪﻟﯿﺔ ﺑﯿﻊ ﺑﺎﻟﺘﻔﺼﯿﻞ*‬
‫ﺻﻧف "ب"‬ ‫ﺻﻧف "أ"‬
‫إﺣداث‬

‫إﺣﺎﻟﺔ‬

‫ﻧﻘل‬
‫‪...........................................................................................................................................................................‬‬ ‫اﻻﺳم واﻟﻠﻘب)**( ‪:‬‬
‫‪....................................................................................................................................................................‬‬ ‫ﺗﺎرﯾﺦ اﻟوﻻدة و ﻣﻛﺎﻧﮭﺎ ‪:‬‬

‫‪............................................................................................................................................................‬‬ ‫رﻗم ﺑطﺎﻗﺔ اﻟﺗﻌرﯾف اﻟوطﻧﯾﺔ ‪:‬‬

‫‪..........................................................‬‬ ‫اﻟﻛﻠﯾﺔ اﻟﺗﻲ أﺳﻧدت ﺷﮭﺎدة ﺻﯾدﻟﻲ ‪ .............................................................................. :‬اﻟﺗﺎرﯾﺦ‬

‫‪20-1.054-02‬‬
‫‪....................................................... ...............................................................................................................‬‬ ‫ﺗﺎرﯾﺦ ﺷﮭﺎدة اﻟﻣﻌﺎدﻟﺔ ‪:‬‬
‫‪............................................................................................................................................‬‬ ‫ﻋدد اﻟﺗرﺳﯾم ﺑﻌﻣﺎدة اﻟﺻﯾﺎدﻟﺔ و ﺗﺎرﯾﺧﮫ ‪:‬‬
‫‪...........................................................................................................................................................................‬‬ ‫اﻟﻌﻧوان اﻟﺷﺧﺻﻲ ‪:‬‬
‫‪.........................................................................................................................................................................‬‬ ‫اﻟﻌﻧوان اﻹﻟﻛﺗروﻧﻲ ‪:‬‬
‫‪................................................................................................‬اﻟﻔﺎﻛس‪................................................................................ :‬‬ ‫اﻟﮭﺎﺗف‪:‬‬
‫‪......................................................................................................................................................‬‬ ‫ﻋﻧوان اﻟﺻﯾدﻟﯾﺔ اﻟﻣزﻣﻊ إﺣداﺛﮭﺎ ‪:‬‬
‫‪........................................................................................................................................‬‬ ‫اﻟﻌﻧوان اﻟﺣﺎﻟﻲ ﻟﻠﺻﯾدﻟﯾﺔ ) ﻓﻲ ﺣﺎﻟﺔ ﻧﻘﻠﮭﺎ( ‪:‬‬
‫‪..........................................................................................................................................‬‬ ‫اﻟﻌﻧوان اﻟﺟدﯾد ﻟﻠﺻﯾدﻟﯾﺔ )ﻓﻲ ﺣﺎﻟﺔ ﻧﻘﻠﮭﺎ( ‪:‬‬
‫‪...............................................................................................................................................‬‬ ‫ﻋﻧوان اﻟﺻﯾدﻟﯾﺔ )ﻓﻲ ﺻورة اﻹﺣﺎﻟﺔ( ‪:‬‬
‫‪................................................................................................................................................................‬‬ ‫اﺳم اﻟﺻﯾدﻟﻲ اﻟﻣﺣﯾل وﻟﻘﺑﮫ‪:‬‬
‫‪..................................................................................................................................................................‬‬ ‫اﻟوﺿﻌﯾﺔ اﻟﻣﮭﻧﯾﺔ اﻟﺣﺎﻟﯾّﺔ ‪:‬‬

‫اﻟﺗزام ‪ :‬أﻟﺗزم ﺑﺄن ﺗﻛون اﻟﺻﯾدﻟﯾﺔ ﺗﺣت ﺗﺻرﻓﻲ و ﻣﺳؤوﻟﯾﺗﻲ ﺑﺻﻔﺔ ﺷﺧﺻ ّﯾﺔ‪.‬‬

‫ﺑـ‪............................‬‬ ‫ﺣرر‬
‫ﻓﻲ‪..............................‬‬

‫اﻹﻣﺿﺎء )ﻣﻌرف ﺑﮫ(‬

‫ﻣﻼﺣظﺔ ‪ :‬ﯾﻌﻣر ھذا اﻟطﻠب ﻓﻲ ﺛﻼﺛﺔ ﻧظﺎﺋر‪.‬‬

‫)*( ﺗوﺿﻊ ﻋﻼﻣﺔ )×( ﻓﻲ اﻟﺧﺎﻧﺔ اﻟﻣﻧﺎﺳﺑﺔ‪.‬‬

‫)**( ﺑﺎﻟﻧﺳﺑﺔ ﻟﻠﺳﯾدة اﻟﻣﺗزوﺟﺔ ﺗذﻛر ﺣرم ﻓﻼن إﺿﺎﻓﺔ إﻟﻰ ﻟﻘﺑﮭﺎ‪.‬‬