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‫اﻟﺟﻣﮭورﯾﺔ اﻟﺗوﻧﺳﯾﺔ‬

‫وزارة اﻟﺗﻌﻠﯾم اﻟﻌﺎﻟﻲ و اﻟﺑﺣث اﻟﻌﻠﻣﻲ‬


‫ﺟﺎﻣﻌﺔ اﻟﻘﯾروان‬
‫اﻟﻣﻌﮭد اﻟﻌﺎﻟﻲ ﻟﻠﻌﻠوم اﻟﺗطﺑﯾﻘﯾﺔ و اﻟﺗﻛﻧوﻟوﺟﯾﺎ ﺑﺎﻟﻘﺻرﯾن‬

‫ﺗﺻرﯾﺢ ﻋﻠﻰ اﻟﺷرف‬


‫إﻧﻲ اﻟﻣﻣﺿﻲ اﺳﻔﻠﮫ ‪.......................................................................................‬‬
‫ﺻﺎﺣﺑ ـ ) ة ( ﺑطﺎﻗﺔ ﺗﻌرﯾف وطﻧﯾﺔ ‪...................................................................... :‬‬
‫اﻟﻘﺎطن ) ة ( ‪................................................................................................... :‬‬
‫اﺻرح ﻋﻠﻰ ﺷرﻓﻲ ﺑﻌدم ﺗﻌﺎطﻲ اي ﻧﺷﺎط ﻣﮭﻧﻲ آﺧر ﺑﻣﻘﺎﺑل ﺧﻼل اﻟﺳﻧﺔ اﻟﺟﺎﻣﻌﯾﺔ ‪20…. - 20….‬‬
‫اﻟﻘﺻرﯾن ﻓﻲ ‪.............................................. :‬‬
‫اﻟﺗﻌرﯾف ﺑﺎﻹﻣﺿﺎء‬

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