‫ﺑﺴﻢ اﷲ اﻟﺮﺣﻤﻦ اﻟﺮﺣﯿﻢ‬

‫اﺳﻢ اﻟﻌﺎﻣﻞ ‪:‬‬

‫ﻣﺼﺪره ‪:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎرﯾﺨﮫ ‪:‬‬ ‫رﻗﻢ اﻟﺠﻮاز ‪:‬‬ ‫اﻟﺠﻨﺴﯿﺔ ‪:‬‬
‫‪/‬‬ ‫‪/‬‬ ‫ﺗﺎرﯾﺦ اﻧﺘﮭﺎء اﻟﻌﻤﻞ ‪:‬‬ ‫‪/ /‬‬ ‫ﺗﺎرﯾﺦ ﻣﺒﺎﺷﺮة اﻟﻌﻤﻞ ‪:‬‬

‫ﺑﯿﺎن ﺑﺼﺮف رواﺗﺐ و أﺟﻮر اﻟﻌﺎﻣﻞ ﻟﺪى‪/‬‬

‫ﻤﻼﺤﻅﺎﺕ‬ ‫ﺍﻟﺘﻭﻗﻴﻊ‬ ‫ﺍﻟﺭﺍﺘﺏ‬ ‫ﺍﻟﺘﺎﺭﻴﺦ‬ ‫ﺍﻟﺸﻬﺭ‬ ‫ﻡ‬

‫‪Notes‬‬ ‫‪Signature‬‬ ‫‪Salary‬‬ ‫‪Date‬‬ ‫‪Month‬‬ ‫‪No‬‬
‫‪١‬‬
‫‪٢‬‬
‫‪٣‬‬
‫‪٤‬‬
‫‪٥‬‬
‫‪٦‬‬
‫‪٧‬‬
‫‪٨‬‬
‫‪٩‬‬
‫‪١٠‬‬
‫‪١١‬‬
‫‪١٢‬‬
‫‪١٣‬‬
‫‪١٤‬‬
‫‪١٥‬‬
‫‪١٦‬‬
‫‪١٧‬‬
‫‪١٨‬‬
‫‪١٩‬‬
‫‪٢٠‬‬
‫‪٢١‬‬
‫‪٢٢‬‬
‫‪٢٣‬‬
‫‪٢٤‬‬

‫‪The undersign hereby do state and‬‬

‫‪acknowledge that my work services has‬‬ ‫ﺍﻗﺭ ﺃﻨﺎ ﺍﻟﻤﻭﻗﻊ ﺃﺩﻨﺎﻩ ﺃﻨﻪ ﻗﺩ ﺍﻨﺘﻬﺕ ﺨﺩﻤﺘﻲ ﻟﺩﻱ ﻜﻔﻴﻠﻲ‬
‫‪completely finished from my employer‬‬ ‫‪..................................................‬‬
‫‪Mr. ........................................................‬‬
‫‪And I have received all my salaries and rights.‬‬ ‫ﻭﺃﻨﻨﻲ ﻗﺩ ﺍﺴﺘﻠﻤﺕ ﺠﻤﻴﻊ ﺭﻭﺍﺘﺒﻲ ﻭﻜﺎﻓﺔ ﺤﻘﻭﻗﻲ ﻭﺃﺒﺭﻱ ﺫﻤﺔ ﻜﻔﻴﻠﻲ‬
‫‪Truly Yours,‬‬
‫ﻭﺍﺨﻠﻲ ﻁﺭﻓﺔ ﻤﻥ ﺠﻤﻴﻊ ﺍﻟﺤﻘﻭﻕ‪ ،‬ﻓﻴﻤﺎ ﻴﺘﻌﻠﻕ ﺒﺨﺩﻤﺘﻲ‪ ،‬ﻭﻋﻠﻴﻪ ﺃﻭﻗﻊ‬
‫‪Name : ........................................................‬‬ ‫اﻻﺳﻢ ‪........................................ :‬‬
‫‪Signature :‬‬ ‫اﻟﺘﻮﻗﯿﻊ ‪:‬‬
‫‪Date :‬‬ ‫‪/‬‬ ‫‪/20‬‬ ‫‪١٤‬ھـ‬ ‫‪/‬‬ ‫‪/‬‬ ‫اﻟﺘﺎرﯾﺦ ‪:‬‬
‫‪http://www.passport.gov.sa‬‬