‫ﺗﺼﺮﯾﺢ أﺑﻮي ﻟﻔﺘﺢ ﺣﺴﺎب ﺑﺮﯾﺪي ﺟﺎري‬

‫‪.................................................................................................................‬‬ ‫أﻧﺎ اﻟﻤﻤﻀﻲ أﺳﻔﻠـﮫ اﻟﺴﯿــﺪ)ة( ‪:‬‬

‫‪...........................................................................‬‬ ‫اﻟﻤﻮﻟـﻮد)ة( ﺑﺘﺎرﯾـﺦ ‪.............................................. :‬ﺑــ‪:‬‬
‫‪.....................................................................................................‬‬ ‫واﻟﺤﺎﻣـﻞ)ة( ﻟـ )ب‪.‬ت‪.‬و(‪)/‬ر‪.‬س( رﻗـﻢ‪:‬‬
‫‪.......................................................................‬‬‫اﻟﺼﺎدرة ﺑﺘﺎرﯾـﺦ‪.............................................:‬ﻋﻦ داﺋــﺮة ‪:‬‬
‫‪............................................................................................................................................‬‬ ‫وﻻﯾــــــﺔ ‪:‬‬
‫أﺻـﺮح ﺑﺸﺮﻓـﻲ أﻧﻨـﻲ أﺳﻤـﺢ اﻟﻤﻮاﻓﻘــﺔ ﻟــ‪:‬‬
‫‪......................................................................................................................................‬‬ ‫وﻟـﺪي )اﺑﻨﺘﻲ( ‪:‬‬
‫‪..........................................................................‬‬ ‫اﻟﻤﻮﻟـﻮد )ة( ﺑﺘﺎرﯾـﺦ ‪............................................... :‬ﺑــ‪:‬‬
‫ﻣﻦ أﺟـــﻞ ‪:‬‬
‫ﻓﺘﺢ ﺣﺴﺎب ﺑﺮﯾﺪي ﺟﺎري‬
‫‪..........................................‬‬ ‫ﺣﺮر ﺑﺘﺎرﯾــﺦ‪:‬‬

‫ﻣﺼــﺎدﻗﺔ اﻟﺒﻠﺪﯾــﺔ‬ ‫إﻣﻀــﺎء اﻟﻤﻌﻨـﻲ‬