‫رﻗﻢ اﻟﻤﻠﻒ‬

‫اﻟﻠﺠﻨﺔ‬
‫ﺼﻭﺭﺓ ﺸﺨﺼﻴﺔ‬
‫‪٦×٤‬‬ ‫ﻃﻠﺐ اﻟﺘﺤﺎق ﺑﻜﻠﻴﺔ اﻟﺸﺮﻃﺔ‬
‫ﺗﺎرﻳﺦ اﻟﺤﺼﻮل ﻋﻠﻰ اﻟﺜﺎﻧﻮﻳﺔ اﻟﻌﺎﻣﺔ أو اﻷزهﺮﻳﺔ‬ ‫ﺍﻟﺴﻴﺩ ﺍﻟﻠﻭﺍﺀ ‪ /‬ﻤﺩﻴﺭ ﻜﻠﻴﺔ ﺍﻟﺸﺭﻁﺔ‬

‫ﺘﺤﻴﺔ ﻁﻴﺒﺔ ﻭﺒﻌﺩ ‪،،،‬‬

‫ﻟﻺﻟﺘﺤﺎﻕ ﺒﻜﻠﻴﺔ ﺍﻟﺸﺭﻁﺔ ﻤﻊ ﺍﻹﺤﺎﻁﺔ‬ ‫‪..................................................................‬‬ ‫ﺃﺭﺠﻭ ﺍﻟﻤﻭﺍﻓﻘﺔ ﻋﻠﻰ ﻗﺒﻭل ﺃﻭﺭﺍﻕ ﺍﻟﻁﺎﻟﺏ ‪:‬‬
‫ﺒﺄﻥ ﺒﻴﺎﻨﺎﺘﻪ ﻜﻤﺎ ﻴﻠﻰ ‪:‬‬
‫ﺒﻴﺎﻨﺎﺕ ﺍﻟﻁﺎﻟﺏ ‪:‬‬
‫* ﺩﺭﺠﺎﺕ ﺍﻟﻁﺎﻟﺏ ﺍﻟﺤﺎﺼل ﻋﻠﻰ ﺍﻟﺜﺎﻨﻭﻴﺔ ﺍﻟﻌﺎﻤﺔ ‪:‬‬
‫‪......................‬‬ ‫ﺭﻗﻡ ﺠﻠﻭﺱ ﺍﻟﺴﻨﺔ ﺍﻟﺜﺎﻟﺜﺔ ‪:‬‬ ‫‪........................‬‬ ‫ﺍﻟﻨﺴﺒﺔ ﺍﻟﻤﺌﻭﻴﺔ ‪:‬‬ ‫‪..........................................‬‬ ‫ﻤﺠﻤﻭﻉ ﺍﻟﺩﺭﺠﺎﺕ ‪:‬‬
‫‪............................................................................................................................. :‬‬ ‫ﻤﻜﺎﻥ ﺍﻟﺤﺼﻭل ﻋﻠﻰ ﺍﻟﻤﺅﻫل ‪ :‬ﺍﻟﻤﺩﺭﺴﺔ‬
‫‪.........................................................‬‬ ‫ﺍﻹﺩﺍﺭﺓ ﺍﻟﺘﻌﻠﻴﻤﻴﺔ ‪ ....................................................................................... :‬ﺍﻟﺸﻌﺒﺔ ‪:‬‬
‫‪.........................................................‬‬ ‫ﻤﺤل ﺍﻟﻤﻴﻼﺩ ‪:‬‬ ‫‪..................................................................................‬‬ ‫ﺘﺎﺭﻴﺦ ﺍﻟﻤﻴﻼﺩ ‪:‬‬
‫‪....................................................................................................................................................................‬‬ ‫ﻤﺤل ﺍﻹﻗﺎﻤﺔ ‪:‬‬
‫‪........................................................................‬‬ ‫ﺭﻗﻡ ﺍﻟﺘﻠﻴﻔﻭﻥ ‪ :‬ﺍﻟﻤﻨﺯل ‪ ............................................................. :‬ﻤﺤﻤﻭل ‪:‬‬
‫ﺒﻴﺎﻨﺎﺕ ﺍﻷﺴﺭﺓ ‪:‬‬
‫‪......................................................................‬‬ ‫ﺍﻟﻤﺅﻫل ‪:‬‬ ‫‪..............................................................................‬‬ ‫ﺃﺴﻡ ﺍﻟﻭﺍﻟﺩ ‪:‬‬
‫)ﻤﻊ ﺇﺭﻓﺎﻕ ﺃﺼل ﺍﻟﻤﺴﺘﻨﺩ ﺍﻟﺩﺍل ﻋﻠﻰ ﺍﻟﻤﺅﻫل ﻭﺍﻟﻭﻅﻴﻔﺔ(‬ ‫‪...............................................................................‬‬ ‫ﻭﻅﻴﻔﺔ ﺍﻟﻭﺍﻟﺩ ‪:‬‬
‫‪.................................................‬‬ ‫ﻋﻤل ‪ .................................. :‬ﻤﺤﻤﻭل ‪:‬‬ ‫‪.....................................‬‬ ‫ﺭﻗﻡ ﺍﻟﺘﻠﻴﻔﻭﻥ ‪ :‬ﺍﻟﻤﻨﺯل ‪:‬‬
‫‪...............................................................‬‬ ‫ﺍﻟﻤﺅﻫل ‪:‬‬ ‫‪..............................................................................‬‬ ‫ﺃﺴﻡ ﻭﻟﻰ ﺍﻷﻤﺭ ‪:‬‬
‫)ﻤﻊ ﺇﺭﻓﺎﻕ ﺃﺼل ﺍﻟﻤﺴﺘﻨﺩ ﺍﻟﺩﺍل ﻋﻠﻰ ﺍﻟﻤﺅﻫل ﻭﺍﻟﻭﻅﻴﻔﺔ(‬ ‫‪.......................................................................‬‬ ‫ﻭﻅﻴﻔﺔ ﻭﻟﻰ ﺍﻷﻤﺭ ‪:‬‬
‫‪......................................................................‬‬ ‫ﺍﻟﻤﺅﻫل ‪:‬‬ ‫‪.............................................................................‬‬ ‫ﺃﺴﻡ ﺍﻟﻭﺍﻟﺩﺓ ‪:‬‬
‫)ﻤﻊ ﺇﺭﻓﺎﻕ ﺃﺼل ﺍﻟﻤﺴﺘﻨﺩ ﺍﻟﺩﺍل ﻋﻠﻰ ﺍﻟﻤﺅﻫل ﻭﺍﻟﻭﻅﻴﻔﺔ(‬ ‫‪.............................................................................‬‬ ‫ﻭﻅﻴﻔﺔ ﺍﻟﻭﺍﻟﺩﺓ ‪:‬‬
‫ﺍﻷﺨﻭﺍﺕ‬ ‫ﺍﻷﺨﻭﺓ‬
‫ﺍﻟﻭﻅﻴﻔﺔ‬ ‫ﺍﻷﺴﻡ‬ ‫ﻤﺴﻠﺴل‬ ‫ﺍﻟﻭﻅﻴﻔﺔ‬ ‫ﺍﻷﺴﻡ‬ ‫ﻤﺴﻠﺴل‬

‫ﻭﺘﻔﻀﻠﻭﺍ ﺒﻘﺒﻭل ﻭﺍﻓﺭ ﺍﻹﺤﺘﺭﺍﻡ ‪،،،‬‬

‫ﺘﻭﻗﻴﻊ ﺍﻟﻭﺍﻟﺩ ‪ /‬ﻭﻟﻰ ﺍﻷﻤﺭ ‪:‬‬ ‫ﺘﻭﻗﻴﻊ ﺍﻟﻁﺎﻟﺏ ‪:‬‬
‫ﺒﻁﺎﻗـﺔ ﻋﺎﺌﻠﻴـــــﺔ ‪:‬‬ ‫ﺒﻁﺎﻗﺔ ﺸﺨﺼﻴﺔ ‪:‬‬
 ‫ﺍﻷﻋﻤـــــﺎﻡ‬
‫ﺍﻟﻤﺅﻫل ﺍﻟﺩﺭﺍﺴﻰ‬ ‫ﺍﻟﻭﻅﻴﻔﺔ ﻭﻤﻜﺎﻥ ﺍﻟﻌﻤل‬ ‫ﺍﻷﺴﻡ‬ ‫ﻤﺴﻠﺴل‬

‫ﺍﻷﺨﻭل‬
‫ﺍﻟﻤﺅﻫل ﺍﻟﺩﺭﺍﺴﻰ‬ ‫ﺍﻟﻭﻅﻴﻔﺔ ﻭﻤﻜﺎﻥ ﺍﻟﻌﻤل‬ ‫ﺍﻷﺴﻡ‬ ‫ﻤﺴﻠﺴل‬

‫‪...........................................................................................................‬‬ ‫ﺃﺴﻡ ﺍﻟﺠﺩ ﻟﻠﻭﺍﻟﺩ ﻭﻭﻅﻴﻔﺘﻪ ﻭﺍﻟﻤﺅﻫل )ﻭﻟﻭ ﻜﺎﻥ ﻤﺘﻭﻓﻴﹰﺎ(‬

‫‪..........................................................................................................‬‬ ‫ﺃﺴﻡ ﺍﻟﺠﺩ ﻟﻠﻭﺍﻟﺩﺓ ﻭﻭﻅﻴﻔﺘﻪ ﻭﺍﻟﻤﺅﻫل )ﻭﻟﻭ ﻜﺎﻥ ﻤﺘﻭﻓﻴﹰﺎ(‬
‫*ﻤﺭﺍﻋﺎﺓ ﺍﻟﺩﻗﺔ ﻓﻰ ﺇﺜﺒﺎﺕ ﺍﻟﻁﺎﻟﺏ ﻟﻬﺫﻩ ﺍﻟﺒﻴﺎﻨﺎﺕ ﻴﺩل ﻋﻠﻰ ﺘﻜﺎﻤل ﺸﺨﺼﻴﺘﻪ ﻭﻤﺩﻯ ﺍﻟﺘﺭﺍﺒﻁ ﺍﻷﺴﺭﻯ ﺍﻟﺫﻯ ﻴﺘﻤﺘﻊ ﺒﻪ ﻭﻫﻤﺎ ﻤﺤـل‬
‫ﺘﻘﺩﻴﺭ ‪.‬‬
‫ﺇﻗــــﺭﺍﺭ‬
‫ﺃﻗﺭ ﺃﻨﺎ ﺍﻟﻁﺎﻟﺏ ‪ ............................................................................................. /‬ﺭﺍﻏﺏ ﺍﻹﻟﺘﺤﺎﻕ ﻜﻁﺎﻟﺏ ﺘﺤﺕ ﺍﻹﺨﺘﺒﺎﺭ ﺒﻜﻠﻴﺔ‬
‫ﺍﻟﺸﺭﻁﺔ ﺒﺄﻥ ﺍﻟﺒﻴﺎﻨﺎﺕ ﺍﻟﻭﺍﺭﺩﺓ ﺒﻁﻠﺏ ﺍﻹﻟﺘﺤﺎﻕ ﺼﺤﻴﺤﺔ ﺘﻤﺎﻤﹰﺎ ﻭﻤﻁﺎﺒﻘﺔ ﻟﻠﺤﻘﻴﻘﺔ ﻭﺃﻨﻰ ﻤﺴﺌﻭل ﻤﺴﺌﻭﻟﻴﺔ ﻜﺎﻤﻠﺔ ﻋﻥ ﺃﻯ ﻤﺨﺎﻟﻔﺔ ﺃﻭ‬
‫ﺨﻁﺄ ﻓﻰ ﻫﺫﻩ ﺍﻟﺒﻴﺎﻨﺎﺕ ﻏﻴﺭ ﺼﺤﻴﺤﺔ ﻭﻏﻴﺭ ﻤﻁﺎﺒﻘﺔ ﻟﻠﻭﺍﻗﻊ ﺃﻭ ﺘﺒﻴﻥ ﺇﻏﻔﺎل ﺒﻴﺎﻨﺎﺕ ﻤﻁﻠﻭﺏ ﺇﺜﺒﺎﺘﻬﺎ ﺃﻭ ﺘﺒﻴﻥ ﺇﺜﺒﺎﺕ ﺒﻴﺎﻨﺎﺕ ﻏﻴـﺭ‬
‫ﺼﺤﻴﺤﺔ ﺒﺼﻔﺔ ﻋﺎﻤﺔ ‪.‬‬

‫‪..........................................‬‬ ‫ﺭﻗﻡ ﺍﻟﺒﻁﺎﻗﺔ ﺍﻟﺸﺨﺼﻴﺔ ‪:‬‬ ‫‪.........................................................‬‬ ‫ﺘﻭﻗﻴﻊ ﺍﻟﻁﺎﻟﺏ ‪:‬‬

‫‪...........................................‬‬ ‫ﺠﻬﺔ ﺍﻹﺼــــﺩﺍﺭ ‪:‬‬
‫‪.............................................‬‬ ‫ﺘﺎﺭﻴﺦ ﺍﻟﺼـــﺩﻭﺭ ‪:‬‬ ‫‪٢٠٠ /‬‬ ‫‪/‬‬ ‫ﺘﺤﺭﻴﺭﹰﺍ ﻓﻰ‬