‫اﻟﺟﻣﮭورﯾﺔ اﻟﺟزاﺋرﯾﺔ اﻟدﯾﻣﻘراطﯾﺔ اﻟﺷﻌﺑﯾﺔ‬

‫وزارة اﻟﺗﻌﻠﯾم اﻟﻌﺎﻟﻲ واﻟﺑﺣث اﻟﻌﻠﻣﻲ‬

‫اﻟﻣرﻛز اﻟﺟﺎﻣﻌﻲ ﻣرﺳﻠﻲ ﻋﺑد ﷲ ‪-‬ﺗﯾﺑﺎزة‪-‬‬
‫اﻟﻠﺟﻧﺔ اﻟﻣﺣﻠﯾﺔ ﻟﻠﺳﻛن‬
‫ﻣﻌﮭد‪............................... :‬‬
‫ﻣﻠــــف اﻟﺳﻛـــــن‬
‫ﻓﺋــــﺔ اﻟﻣدرﺳــــــﯾن‬
‫أو ﻻ ‪ :‬اﻟﺣ ﺎﻟﺔ اﻟﻣ د ﻧﯾﺔ ‪:‬‬

‫اﻻ ﺳ م ‪.................................:‬اﻟﻠﻘ ب ‪ ............................................:‬اﻟﻠﻘ ب اﻷ ﺻ ﻠ ﻲ‬

‫ﻟ ﻠ ﻣ ﺗ ز و ﺟ ﺔ ‪....................................:‬‬
‫ﺗ ﺎر ﯾﺦ‬
‫اﻟﻣ ﯾﻼ د ‪...............................................................................:‬ﻣ ﻛ ﺎﻧﮫ ‪........ ................................:‬‬
‫‪..............‬‬
‫اﻟﻌ ﻧو ان ‪.............................. ...............................................................................................:‬‬
‫‪............................‬‬
‫ﺣ ﺎﻟﺔ أﺧ ر ى ) ﺣ د د ھ ﺎ(‬ ‫ﻣ ﺗز و ج ) ة(‬ ‫اﻟﺣ ﺎﻟﺔ اﻟﻌ ﺎﺋﻠﯾﺔ ‪ :‬أﻋ ز ب ‪ /‬ﻋ ز ﺑ ﺎء‬
‫ﻋ د د اﻷ و ﻻ د‪...............................:‬أﺷ ﺧ ﺎص ﺗﺣ ت‬
‫اﻟﻛ ﻔ ﺎﻟﺔ ‪............................. .......................... ...... ....................:‬‬
‫اﻻ ﺳ م‬ ‫اﻟز و ج ) ة( ﺗ ﺎﺑﻊ ) ة( ﻟﻘط ﺎع اﻟﺗ د ر ﯾ س ﺑ ﺎﻟﺗﻌ ﻠﯾم اﻟﻌ ﺎﻟﻲ ‪ :‬ﻧﻌ م‬
‫و ا ﻟ ﻠﻘ ب ‪. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . :‬‬
‫ﻻ‬

‫ﺛ ﺎ ﻧ ﯾ ﺎ‪ :‬اﻟﺣ ﺎﻟﺔ اﻟﻣ ﮭ ﻧ ﯾ ﺔ ‪:‬‬

‫اﻟر ﺗﺑﺔ ‪ ......................................:‬ﺗ ﺎر ﯾﺦ اﻟﺗو ظ ﯾف ﺑﻘط ﺎع اﻟﺗﻌ ﻠﯾم‬

‫اﻟﻌ ﺎﻟﻲ ‪.................................... ...........................:‬‬
‫اﻟو ظ ﯾﻔﺔ ‪................................................:‬ﻣ ﻌ ﮭ د ‪/‬ﻗﺳ م ‪..... ............................................................:‬‬
‫‪......................‬‬
‫اﻟﻣ ﺳ ؤ و ﻟﯾﺔ اﻹ د ار ﯾﺔ‬
‫ﺑﺎﻟﻣؤﺳﺳﺔ‪..........................................................................................................................:‬‬
 ‫ﺛ ﺎﻟﺛ ﺎ‪ :‬ﺟ ز ء ﻣ ﺧ ﺻ ص ﻟﻺ د ار ة ‪ :‬ﺗ ﻌ ﯾ ﯾن اﻟﺳ ﻛ ن‬

‫ﯾﻘﻊ‬ ‫ﻏرف‬ ‫ﻣ ن ‪........................ .....................:‬‬ ‫ﯾﺗﻛ و ن‬ ‫ﺳ ﻛن‬

‫ب ‪. . . . . . . . . ............................................................:‬‬
‫ر ﻗم‬ ‫ا ﻟط ﺎ ﺑ ق ‪. . . . . . . . . . . . . . . . . . . . . . . . . . :‬‬ ‫ا ﻟ ﺳ ﻠ م ‪ . . . . . . . . . . . . . . . . . . . . . .. . . :‬ر ﻗ م‬ ‫اﻟﻌ ﻣ ﺎر ة‪..................:‬ر ﻗم‬ ‫ر ﻗم‬
‫اﻟﺷ ﻘﺔ ‪...........................:‬‬
‫ﻣﻼ ﺣ ظ ﺎت‬
‫أﺧ ر ى ‪. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ............................................................................................:‬‬
‫‪...........‬‬

‫ﺗو ﻗﯾﻊ ر ﺋﯾس ﻟﺟ ﻧﺔ اﻟﺳ ﻛ ن‬ ‫ﺗو ﻗﯾﻊ اﻟﻣ ﻌ ﻧﻲ‬

‫ﺗو ﻗﯾﻊ ﻣ د ﯾر اﻟﻣ ؤ ﺳ ﺳ ﺔ‬