‫ﺨﺎﺹ ﺒﺎﻝﻤﺨﺎﻁﺏ ﺍﻝﻭﺤﻴﺩ‬ ‫ا ر  ا‬

‫ﺭﻗــﻡ ﺍﻹﻴــﺩﺍﻉ‬ ‫وزارة ‪.......................‬‬

‫ا  ا ‬
‫ﺘﺎﺭﻴــﺦ ﺍﻹﻴـﺩﺍﻉ‬
‫!  وع دي‬ ‫و ‪.........................‬‬

‫‪ I‬ـ ﺍﻝﺒﺎﻋـــﺙ ‪:‬‬

‫ﺍﻻﺴﻡ ‪................................ :‬ﺍﻝﻠﻘﺏ ‪ ......................... :‬ﺍﺴﻡ ﺍﻝﻘﺭﻴﻥ ‪............................:‬‬
‫ﻤﻜﺎﻨﻬﺎ ‪...................................................... :‬‬ ‫ﺘﺎﺭﻴﺦ ﺍﻝﻭﻻﺩﺓ ‪:‬‬
‫ﺍﻝﻴﻭﻡ ﺍﻝﺸﻬﺭ ﺍﻝﺴﻨــﺔ‬
‫ﺘﺎﺭﻴﺦ ﺇﺼﺩﺍﺭﻫﺎ ﻭﻤﻜﺎﻨﻪ‪......................... :‬‬ ‫ﺭﻗﻡ ﺒﻁﺎﻗﺔ ﺍﻝﺘﻌﺭﻴﻑ ﺍﻝﻭﻁﻨﻴﺔ ‪:‬‬
‫ﺍﻝﻌﻨﻭﺍﻥ ﺍﻝﺸﺨﺼﻲ ‪............................................................................................... :‬‬
‫ﺍﻝﻤﺅﻫل ﺍﻝﺘﻌﻠﻴﻤﻲ ﺃﻭ ﺍﻝﺘﻜﻭﻴﻨﻲ ﻭﺍﻝﺘﺠﺭﺒﺔ ﺍﻝﻤﻬﻨﻴﺔ ‪.................................................................. :‬‬

‫‪ II‬ـ ﺨﺎﺼﻴﺎﺕ ﺍﻝﻤﺸﺭﻭﻉ ﺍﻝﻔﺭﺩﻱ ‪:‬‬

‫ﺍﻝﻨﺸﺎﻁ )‪..................................................... : (1‬ﺍﻻﺴﻡ ﺍﻝﺘﺠﺎﺭﻱ ‪................................:‬‬
‫ﻋﺩﺩ ﻤﻭﺍﻁﻥ ﺍﻝﺸﻐل ‪:‬‬ ‫ﺸﺭﺍﺀ‬ ‫ﺘﻭﺴﻴﻊ‬ ‫ﺇﺤﺩﺍﺙ‬ ‫ﻁﺒﻴﻌﺔ ﺍﻝﻤﺸﺭﻭﻉ )‪: (2‬‬

‫‪07-4.064-02‬‬
‫ﻤﺼﺩﺭﺓ ﺠﺯﺌﻴﺎ‬ ‫ﻤﺼﺩﺭﺓ ﻜﻠﻴﺎ‬
‫ﺍﻝﻤﺴﺎﺤﺔ ﺍﻝﻤﺴﺘﻌﻤﻠﺔ )‪ (3‬ﺴﻘﻭﻴﺎ ‪ .................... :‬ﺒﻌﻠﻴﺎ ‪ ................... :‬ﻤﺸﺠﺭﺓ ‪......................:‬‬
‫ﻤـــــﻠﻙ‬ ‫ﻜـــﺭﺍﺀ‬ ‫ﺼﻴﻐﺔ ﺍﻷﺴﺘﻐﻼل )‪: (2‬‬
‫ﻋﻨﻭﺍﻥ ﺍﻝﻤﺤل ‪................................................................................................... :‬‬
‫ﺍﻝﻭﻻﻴﺔ ‪ ................................... :‬ﺍﻝﻤﻌﺘﻤﺩﻴﺔ ‪ ......................:‬ﺍﻝﺒﻠﺩﻴﺔ ‪............................:‬‬
‫ﻤﻭﺴﻤﻴﺔ‬ ‫ﻭﻗﺘﻴﺔ‬ ‫ﺩﺍﺌﻤﺔ‬ ‫ﺍﻷﻨﺸﻁﺔ ﺍﻝﻤﺘﺩﺍﻭﻝﺔ ﺒﺎﻝﻤﺤل)‪: (2‬‬
‫ﻻ‬ ‫ﻨﻌـــﻡ‬ ‫ﺨﺎﻀﻌﺔ ﻝﻠﺘﺴﺠﻴل ﺒﺎﻝﺴﺠل ﺍﻝﺘﺠﺎﺭﻱ )‪: (2‬‬
‫ﺘﻘﺩﻴــﺭﻱ‬ ‫ﺤﻘﻴﻘــﻲ‬ ‫ﺍﻝﻨﻅﺎﻡ ﺍﻝﺠﺒﺎﺌﻲ )‪: (2‬‬
‫ﻻ‬ ‫ﻨﻌــــﻡ‬ ‫ﻁﻠﺏ ﺍﻻﻨﺘﻔﺎﻉ ﺒﺎﻻﻤﺘﻴﺎﺯﺍﺕ ﺍﻝﺠﺒﺎﺌﻴﺔ ﻭﺍﻝﻤﺎﻝﻴﺔ )‪: (2‬‬
‫ﻤـــــﻠﻙ‬ ‫ﻜـــﺭﺍﺀ‬ ‫ﻁﻠﺏ ﺍﻻﻨﺘﻔﺎﻉ ﺒﻘﺭﺽ ﺒﻨﻜﻲ )‪: (2‬‬
‫ﻤﻥ ﺃﻱ ﺒﻨﻙ ‪..................................................................................................... :‬‬

‫‪ III‬ـ ﺨﺎﺹ ﺒﺎﻻﻨﺨﺭﺍﻁ ﻓﻲ ﺍﻝﺼﻨﺩﻭﻕ ﺍﻝﻭﻁﻨﻲ ﻝﻠﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ ‪:‬‬

‫ﻻ‬ ‫ﻨﻌــــﻡ‬ ‫ﻤﻨﺨﺭﻁ ﻓﻲ ﺍﻝﺼﻨﺩﻭﻕ ﺍﻝﻭﻁﻨﻲ ﻝﻠﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ)‪: (2‬‬
‫ﺭﻗﻡ ﺍﻻﻨﺨﺭﺍﻁ ‪................................................................................................... :‬‬

‫‪--------------------------------------------------------------‬‬
‫)‪ (1‬ﺼﻨﺎﻋﺔ ﺃﻭ ﻓﻼﺤﺔ ﺃﻭ ﺼﻴﺩ ﺒﺤﺭﻱ ﺃﻭ ﺴﻴﺎﺤﺔ ﺃﻭ ﺼﻨﺎﻋﺎﺕ ﺘﻘﻠﻴﺩﻴﺔ ﺃﻭ ﺨﺩﻤﺎﺕ ﺍﻝﻔﻼﺤﺔ ﻭﺍﻝﺼﻴﺩ ﺍﻝﺒﺤﺭﻱ ‪.‬‬
‫)‪ (2‬ﻭﻀﻊ ﻋﻼﻤﺔ × ﻓﻲ ﺍﻝﻤﺭﺒﻊ ﺍﻝﻤﻨﺎﺴﺏ ‪.‬‬
‫)‪ (3‬ﺒﺎﻝﻨﺴﺒﺔ ﻝﻠﻤﺸﺎﺭﻴﻊ ﺍﻝﻔﻼﺤﻴﺔ ‪.‬‬
 ‫‪IV‬ـ ﺠﺩﻭل ﺍﻻﺴﺘﺜﻤﺎﺭ ﻭﺍﻝﺘﻤﻭﻴل ‪:‬‬

‫ﺴﻨﻭﻴﺎ ‪.............................................................................. :‬‬ ‫ﺍﻹﻨﺘﺎﺝ ﺃﻭ ﺍﻝﺨﺩﻤﺎﺕ ﺍﻝﻤﺘﻭﻗﻌﺔ‬

‫ﺍﻝﻤﺒﻠﻎ‬ ‫ﺍﻝﺘﻤﻭﻴل‬ ‫ﺍﻝﻤﺒﻠﻎ‬ ‫ﺍﻻﺴﺘﺜﻤﺎﺭ‬
‫‪ ..........................‬ﺃﻤﻭﺍل ﺫﺍﺘﻴﺔ‪.......................... ................‬‬ ‫ﺍﻷﺭﺽ‪...................‬‬
‫‪ ..........................‬ﻗﺭﻭﺽ ﻁﻭﻴﻠﺔ ﺍﻝﻤﺩﻯ‪.......................... ......‬‬ ‫ﺍﻝﺒﻨﺎﺀﺍﺕ‪...................‬‬
‫‪ ..........................‬ﻗﺭﻭﺽ ﻤﺘﻭﺴﻁﺔ ﺍﻝﻤﺩﻯ‪.......................... ....‬‬ ‫ﺍﻝﺘﻬﻴﺌﺔ‪....................‬‬
‫‪ ..........................‬ﻗﺭﻭﺽ ﺼﻐﻴﺭﺓ ﺍﻝﻤﺩﻯ‪.......................... .....‬‬ ‫ﺍﻝﺘﺠﻬﻴﺯﺍﺕ ﻭﺍﻵﻻﺕ‪.......‬‬
‫‪ ..........................‬ﺍﻋﺘﻤﺎﺩﺍﺕ‪.......................... ..................‬‬ ‫ﻤﻌﺩﺍﺕ ﻓﻼﺤﻴﺔ‪............‬‬
‫‪ ..........................‬ﻤﻨﺢ‪.......................... .......................‬‬ ‫ﻏﺭﺍﺴﺎﺕ‪.................‬‬
‫‪ ..........................‬ﻤﻭﺍﺭﺩ ﺃﺨﺭﻯ‪.......................... ..............‬‬ ‫ﺤﻴﻭﺍﻨﺎﺕ‪..................‬‬
‫‪..........................‬‬ ‫ﻤﻌﺩﺍﺕ ﺍﻝﻨﻘل‪..............‬‬
‫‪..........................‬‬ ‫ﻤﺼﺎﺭﻴﻑ ﻤﺨﺘﻠﻔﺔ‪.........‬‬
‫‪..........................‬‬ ‫ﺍﻝﻤﺎل ﺍﻝﻤﺘﺩﺍﻭل ‪...........‬‬
‫‪..........................‬‬ ‫‪..........................‬‬

‫‪V‬ـ ﺘﺼﺭﻴﺢ ﻋﻠﻰ ﺍﻝﺸﺭﻑ ‪:‬‬

‫ﺇﻨﻲ ﺍﻝﻤﻤﻀﻲ ﺃﺴﻔﻠﻪ ﺃﺸﻬﺩ ﺒﺼﺤﺔ ﺍﻝﺒﻴﺎﻨﺎﺕ ﺍﻝﺘﻲ ﺘﻀﻤﻨﻬﺎ ﻫﺫﺍ ﺍﻝﺘﺼﺭﻴﺢ ﻜﻤﺎ ﺃﺼﺭ‪‬ﺡ ﻋﻠﻰ ﺍﻝﺸﺭﻑ ﺃﻨﻲ ﻝﻡ ﺃﺘﻌﺭﺽ‬
‫ﺇﻝﻰ ﻋﻘﺎﺏ ﺠﺯﺍﺌﻲ ﺃﻭ ﺇﺩﺍﺭﻱ ﻤﻥ ﺸﺄﻨﻪ ﺃﻥ ﻴﺤﺠﺭ ﻋﻠﻲ ﺇﺩﺍﺭﺓ ﺘﺴﻴﻴﺭ ﻤﺅﺴﺴﺔ ﺃﻭ ﺃﻱ ﻨﺸﺎﻁ ﺘﺠﺎﺭﻱ ‪.‬‬

‫‪...................‬ﻓﻲ‪..................‬‬
‫ﺍﻹﻤﻀـــﺎﺀ‬
‫)ﻏﻴﺭ ﻤﻌﺭﻑ ﺒﻪ (‬

‫‪VI‬ـ ﺍﻷﻭﺭﺍﻕ ﺍﻝﻤﺼﺎﺤﺒـﺔ ‪:‬‬

‫‪....................................................................................................... -1‬‬
‫‪....................................................................................................... -2‬‬
‫‪....................................................................................................... -3‬‬
‫‪....................................................................................................... -4‬‬
‫‪....................................................................................................... -5‬‬

‫ﺨﺎﺹ ﺒﺎﻝﻤﺨﺎﻁﺏ ﺍﻝﻭﺤﻴﺩ ‪:‬‬

‫ﺍﻝﻤﻌﺭﻑ ﺍﻝﺠﺒﺎﺌﻲ ‪....................................................................................... :‬‬
‫ﺭﻗﻡ ﺍﻻﻨﺨﺭﺍﻁ ﻓﻲ ﺍﻝﺼﻨﺩﻭﻕ ﺍﻝﻭﻁﻨﻲ ﻝﻠﻀﻤﺎﻥ ﺍﻻﺠﺘﻤﺎﻋﻲ ‪ :‬ﻜﻤﺅﺠﺭ ‪...................................... :‬‬
‫ﻜﻌﺎﻤل ﺃﺠﻴﺭ ‪...................................... :‬‬
‫ﻜﺭﺍﺱ ﺍﻝﺸﺭﻭﻁ ﻤﻤﻀﻰ ﻓﻲ ‪............................................................................. :‬‬
‫ﺘﺭﺨﻴﺹ ﻤﺴﻠﻡ ﻓﻲ ‪ ................................... :‬ﻴﺘﻌﻠﻕ ﺒـ ‪.......................................:‬‬
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