‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺠﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﻳﻤﻘﺮﺍﻁﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ‬

‫ﺟﺎﻣﻌﺔ "ﻋﺒﺎﺱ ﻟﻐﺮﻭﺭ" ﺧﻨﺸﻠﺔ‬

‫ﻟﺠﻨﺔ ﺍﻟﺨﺪﻣﺎﺕ ﺍﻻﺟﺘﻤﺎﻋﻴﺔ‬
‫‪A9‬‬
‫‪..................................................‬‬ ‫ﻣﻠﻑ ﺭﻗﻡ‪:‬‬
‫‪..........................................‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻹﻳﺩﺍﻉ‪:‬‬

‫ﻁﻠﺐ ﺍﻻﺳﺘﻔﺎﺩﺓ ﻣﻦ ﻣﻨﺤﺔ ﻗﻔﺔ ﺭﻣﻀﺎﻥ‬

‫‪..............................................‬‬ ‫ﺍﻟﻠﻘﺐ )ﺍﻟﻤﺴﺘﺨﺪﻡ)ﺓ((‪............................................... :‬ﺍﻟﻠﻘﺐ ﺍﻷﺻﻠﻲ ﻟﻠﻤﺘﺰﻭﺟﺔ‪............................................ :‬ﺍﻻﺳﻢ‪:‬‬
‫‪.......................................................................................................................................‬‬ ‫ﺑـ‪:‬‬ ‫‪...................../............./..............‬‬ ‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻻﺯﺩﻳﺎﺩ‪:‬‬
‫‪...........................................................................‬‬ ‫ﺍﻟﻤﻬــــــــــــــــــــــﻨﺔ‪.......................................................................................... :‬ﺍﻟﻜﻠﻴﺔ )ﺍﻟﻤﺼﻠﺤﺔ(‪:‬‬
‫‪................................................‬‬ ‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﺸﺨﺼﻲ‪..................................................................................................................................... :‬ﺭﻗﻢ ﺍﻟﻬﺎﺗﻒ‪:‬‬
‫‪...............................................................................................................‬‬ ‫ﺍﻟﺮﺍﺗﺐ ﺍﻟﺼﺎﻓﻲ ﺍﻷﺧﻴﺮ )ﺑﺪﻭﻥ ﺃﻱ ﺍﻗﺘﻄﺎﻋﺎﺕ( ‪-‬ﺑﺎﻷﺣﺮﻑ ﻭﺑﺎﻷﺭﻗﺎﻡ‪:-‬‬
‫‪............................................................................................................................................................................................................................................................‬‬

‫‪/‬‬ ‫‪/‬‬
‫‪.................. ............ ............‬‬ ‫ﺣﺮﺭ ﺑـ‪..............................................‬ﻳﻮﻡ‪:‬‬
‫ﺇﻣﻀﺎء ﺍﻟﻤﻌﻨﻲ )ﺓ(‬

‫ﺍﻟﻮﺛﺎﺋﻖ ﺍﻟﻤﻄﻠﻮﺑﺔ‪:‬‬
‫ﺍﻟﻤﺮﺍﻗﺒﺔ‬ ‫ﺍﻟﻤﺮﺍﻗﺒﺔ‬ ‫ﺍﻟﻮﺛﺎﺋﻖ‬
‫ﻣﻼﺣﻈﺎﺕ‬ ‫ﺍﻟﻮﺛﺎﺋﻖ ﺍﻟﻤﻄﻠﻮﺑﺔ‬ ‫ﺍﻟﺮﻗﻢ‬
‫ﺍﻟﺜﺎﻧﻴﺔ‬ ‫ﺍﻷﻭﻟﻰ‬ ‫ﺍﻟﻤﺴﺘﻠﻤﺔ‬
‫ﺍﻻﺳﺘﻤﺎﺭﺓ ‪) A9‬ﻣﺘـــﻮﻓﺮﺓ ﻋﻨﺪ ﻣﺼﺎﻟﺢ ﺍﻟﻠﺠﻨﺔ ﺃﻭ‬ ‫‪01‬‬
‫ﺗﺴﺤﺐ ﻣﻦ ﺻﻔﺤﺘﻬﺎ ﺃﻭ ﺑﻤﻮﻗﻊ ﺍﻟﺠﺎﻣﻌﺔ (‬
‫ﺑﻄﺎﻗﺔ ﻋﺎﺋﻠﻴﺔ ﺃﻭ ﺷﻬﺎﺩﺓ ﻛﻔﺎﻟﺔ‬ ‫‪02‬‬
‫ﻛﺸﻒ ﺍﻟﺮﺍﺗﺐ ﺍﻷﺧﻴﺮ‬ ‫‪03‬‬
‫ﺻﻚ ﻣﺸﻄﻮﺏ )ﻧﺴﺨﺔ(‬ ‫‪04‬‬

‫ﺇﻁﺎﺭ ﺧﺎﺹ ﺑﺎﻟﻠﺠﻨﺔ‪:‬‬

‫ﺗﺄﺷﻴﺮﺓ ﺍﻟﻠﺠﻨﺔ‬ ‫ﻣﺒﻠﻎ ﺍﻻﺳﺘﻔﺎﺩﺓ)ﺍﻟﻤﺪﺍﻭﻟﺔ(‬ ‫ﻗﺮﺍﺭ ﺍﻟﻠﺠﻨﺔ)ﺍﻟﻤﺪﺍﻭﻟﺔ(‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻌﺎﻟﺠﺔ)ﺍﻟﻤﺪﺍﻭﻟﺔ(‬

‫ﻣﻼﺣﻈﺔ‪ :‬ﺗﺴﺪﺩ ﻫﺬﻩ ﺍﻟﻤﻨﺤﺔ ﻣﺮﺓ ﻭﺍﺣﺪﺓ ﻓﻲ ﺍﻟﺴﻨﺔ ﻭﻳﺴﻘﻂ ﺣﻖ ﺍﻻﺳﺘﻔﺎﺩﺓ ﺑﻌﺪ ﺍﻧﻘﻀﺎء ﺍﻟﺴﻨﺔ ﺍﻟﻤﺎﻟﻴﺔ‬
‫‪‬‬

‫ﻭﺻﻞ ﺍﺳﺘﻼﻡ ﻣﻠﻒ ﻁﻠﺐ ﺍﻻﺳﺘﻔﺎﺩﺓ ﻣﻦ ﻣﻨﺤﺔ ﻗﻔﺔ ﺭﻣﻀﺎﻥ‬ ‫‪A9‬‬

‫ﻣﻠﻒ ﺭﻗﻢ‪............................................................ :‬ﺗﺎﺭﻳﺦ ﺇﻳﺪﺍﻉ ﺍﻟﻤﻠﻒ‪.................................... :‬‬
‫ﺍﻟﻠﻘﺐ )ﺍﻟﻤﺴﺘﺨﺪﻡ)ﺓ(( ‪.............................................‬ﺍﻟﻠﻘﺐ ﺍﻷﺻﻠﻲ ﻟﻠﻤﺘﺰﻭﺟﺔ‪.............................. :‬‬
‫ﺍﻻﺳﻢ‪............................................................... :‬‬
‫ﺧﺘﻢ ﺍﻟﻠﺠﻨﺔ‬