‫ﺗــﻮآﻴـــــــــــــــﻞ‬

‫إﻧﻲ اﻟﻤﻤﻀﻲ )ة( أﺳﻔﻠﻪ ‪....................................................................................................‬‬

‫ﺗﻮﻧﺴﻲ )ة( اﻟﺠﻨﺴﻴﺔ ‪ ،‬ﺻﺎﺣﺐ ﺟﻮاز اﻟﺴﻔﺮ \ ﺑﻄﺎﻗﺔ اﻟﺘﻌﺮﻱﻒ اﻟﻮﻃﻨﻴﺔ ﻋﺪد ‪........................................‬‬
‫ﺻﺎدر)ة( ﺑـ ‪ .....................................................‬ﻓﻲ ‪.......................................................‬‬
‫اﻟﻘﺎﻃﻦ )ة( ﺑﺎﻟﻌﻨﻮان اﻟﺘﺎﻟﻲ ‪.................................................................................................‬‬
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‫أﺷﻬﺪ وأﻋﺘﺮف ﺑﺄﻧﻲ وآﻠﺖ اﻟﺴﻴﺪ )ة( ‪....................................................................................‬‬
‫ﺻﺎﺣﺐ ﺟﻮاز اﻟﺴﻔﺮ \ ﺑﻄﺎﻗﺔ اﻟﺘﻌﺮﻱﻒ اﻟﻮﻃﻨﻴﺔ ﻋﺪد ‪..................................................................‬‬
‫ﺻﺎدر)ة( ﺑـ ‪ .....................................................‬ﻓﻲ ‪.......................................................‬‬
‫اﻟﻘﺎﻃﻦ )ة( ﺑﺎﻟﻌﻨﻮان اﻟﺘﺎﻟﻲ ‪.................................................................................................‬‬
‫‪..................................................................................................‬‬
‫ﻟﻴﻨﻮﺑﻨﻲ وﻱﻘﻮم ﻡﻘﺎﻡﻲ ﻓﻲ ‪...................................................................................................‬‬
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‫‪.................................................................................................................................‬‬
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‫وأن آﻞ اﻹﺟﺮاءات اﻟﺘﻲ ﻱﻘﻮم ﺑﻬﺎ اﻟﺴﻴﺪ )ة( ‪............................................................................‬‬
‫ﺑﻤﻮﺟﺐ هﺬا اﻟﺘﻮآﻴﻞ ﺗﻠﺰﻡﻨﻲ اﻟﺘﺰاﻡﺎ ﺗﺎﻡﺎ ﺣﺴﺐ إﻡﻀﺎﺋﻲ أﺳﻔﻠﻪ‪.‬‬

‫‪ ................................‬ﻓﻲ ‪.................................‬‬

‫اﻹﻡﻀـــــــــﺎء‬

‫ﻋﺪد ‪...............................‬‬
‫اﻃﻠﻊ ﻋﻠﻴﻪ ﻟﻠﺘﻌــــــﺮﻱﻒ ﺑﺈﻡﻀـــــــﺎء‬
‫اﻟﺴﻴﺪ ‪......................................‬‬
‫‪ .................‬ﻓﻲ ‪.......................‬‬

‫ﻋﻦ اﻟﻘﻨﺼﻞ اﻟﻌﺎم‬

‫اﻟﻘﻨﺼـــــــــــﻞ‬