‫طﻠﺐ إﺻﺪار‪/‬ﺗﺠﺪﯾﺪ ﺷﮭﺎدة اﻟﺨﺘﻢ اﻹﻟﻜﺘﺮوﻧﻲ‬

‫‪Issue/Renewal of Digital Seal Request‬‬

‫اﻻﺳﻢ )رﺑﺎﻋﻲ( ‪Full Name............................................................................................................................ :‬‬

‫اﻟﺮﻗﻢ اﻟﻘﻮﻣﻲ ‪ /‬ﺟﻮاز اﻟﺴﻔﺮ ‪NID / Passport……................................................................................................:‬‬

‫ﺑﺮﯾﺪ إﻟﻜﺘﺮوﻧﻲ ‪Email…................................................................................................................................:‬‬

‫ﺗﻠﯿﻔﻮن ‪ /‬ﻣﻮﺑﯿﻞ ‪Tel/Mobile…..........................................................................................................................:‬‬

‫اﻟﻌﻨﻮان ‪Address.........................................................................................................................................:‬‬

‫اﻟﻮظﯿﻔﺔ ‪Job Title.........................................................................................................................................:‬‬

‫طﺮﯾﻘﺔ اﻟﺘﺮﻛﯿﺐ ‪........................:‬ﺑﻄﺎﻗﺔ ذﻛﯿﺔ ‪ /‬ﺗﻮﻛﯿﻦ ‪ /‬ﺟﮭﺎز ‪Installation….........................Smart Card\Token\HSM‬‬

‫ﻣﺪة اﻟﺼﻼﺣﯿﺔ ‪Validity………………………................................................................................................:‬‬

‫اﻟﻤﺮﻓﻘﺎت‪ :‬ﺻﻮرة ﺗﺤﻘﯿ ﻖ اﻟ ﺸﺨﺼﯿ ﺔ‪ ،‬ﺻﻮرة اﻟﺒﻄﺎﻗﺔ اﻟﻀﺮﯾﺒﯿﺔ‪ ،‬ﺻﻮرة ﺳﺠﻞ ﺗﺠﺎري ﺣﺪﯾﺚ وﺳﺎري‪ ،‬ﺷﮭﺎدة ﺗﺴﺠﯿﻞ اﻟﻘﯿﻤﺔ اﻟﻤﻀﺎﻓﺔ‪ ،‬إﯾﺼﺎل ﺳﺪاد‬
‫‪Attachments: ID photocopy, Tax Card photocopy, Recent & Valid Commercial Registry photocopy, VAT Registration Certificate, Payment Receipt‬‬
‫‪-------------------------------------------------------------------------------------------------- --------------------------‬‬
‫أﻗﺮ ﺑﺄن ﺟﻤﯿﻊ اﻟﺒﯿﺎﻧﺎت اﻟﻤﺬﻛﻮرة ﻋﺎﻟﯿﮫ ﺻﺤﯿﺤﺔ ﺗﻤﺎﻣﺎ و ﺗﺤﺖ ﻣﺴﺆوﻟﯿﺘﻲ اﻟﺸﺨﺼﯿﺔ‪ ,‬و أﺗﻌﮭﺪ ﺑﺈﺑﻼغ اﻟﺸﺮﻛﺔ ﺣﺎل ﺗﻐﯿﺮھﺎ‪.‬‬
‫‪I declare & agree that all above data are true & correct under my full responsibility, will notify your‬‬
‫‪company in case of any change.‬‬
‫اﻻﺳﻢ ‪Name.................................................................................................................................................‬‬
‫اﻟﺘﻮﻗﯿﻊ ‪Signature..........................................................................................................................................:‬‬
‫‪--------------------------------------- -------------------------------------------------------------------------------------‬‬
‫‪To be Filled by Egypt Trust‬‬ ‫ﯾﺘﻢ ﻣﻸ ھﺬه اﻟﺒﯿﺎﻧﺎت ﺑﻮاﺳﻄﺔ اﻟﺸﺮﻛﺔ اﻟﻤﺼﺮﯾﺔ ﻟﻠﺘﻮﻗﯿﻊ اﻹﻟﻜﺘﺮوﻧﻲ وﺗﺄﻣﯿﻦ اﻟﻤﻌﻮﻣﺎت‬
‫إدارة اﻟﺤﺴﺎﺑﺎت‬
‫طﺮﯾﻘﺔ اﻟﺴﺪاد ‪.......................................................:‬ﻧﻘﺪا ً‪.................‬ﺑﻄﺎﻗﺔ اﺋﺘﻤﺎن‪.................‬أﺧﺮي‪..........................‬‬
‫إﺷﻌﺎر ﺳﺪاد ‪ /‬إﯾﺼﺎل رﻗﻢ ‪............................................:‬روﺟﻊ ﺑﻮاﺳﻄﺔ )ﻣﻮظﻒ اﻟﺤﺴﺎﺑﺎت( ‪.........................................:‬‬
‫‪----------------------------------------------- ----------------------------------------------------- ------------------------‬‬
‫ﺧﺪﻣﺔ اﻟﻌﻤﻼء‬
‫اﻟﻮﻗﺖ‪....................:‬‬ ‫اﺳﺘﻼم و ﻣﺮاﺟﻌﺔ ‪....................................................................................:‬ﺑﺘﺎرﯾﺦ ‪/ /‬‬

‫اﻟﻮﻗﺖ‪....................:‬‬ ‫‪/‬‬ ‫‪/‬‬ ‫إﺻﺪار و ﺗﺴﻠﯿﻢ اﻟﺸﮭﺎدة‪ ..............................................................................:‬ﺑﺘﺎرﯾﺦ‬

‫ﯾﻌﺘﻤﺪ ‪..................................................................................................:‬‬
‫‪------------------------------------------------------------------------------------------- ---------------------------------‬‬
‫ﺑﯿﺎﻧﺎت اﻟﻤﺴﺘﻠﻢ‪Received By‬‬
‫اﻻﺳﻢ‪Name:-------------------------------------------------------------------------- ------------------------------------:‬‬

‫اﻟﺘﻮﻗﯿﻊ‪Signature: ----------------------------------------------------------------- --------------------------------- -------:‬‬

‫ﺑﯿﺎﻧﺎت اﻟﺘﺴﻠﯿﻢ‬
‫إداري ﺧﺪﻣﺔ اﻟﻌﻤﻼء‬ ‫ﺗﺎرﯾﺦ اﻟﺘﺴﻠﯿﻢ‪-‬اﻟﻮﻗﺖ‬ ‫رﻗﻢ اﻟﺒﻮﻟﯿﺼﺔ – ﺷﺮﻛﺔ اﻟﺒﺮﯾﺪ‬ ‫ﺗﺎرﯾﺦ اﻹرﺳﺎل‬
‫اﻟﺘﻮﻛﻦ‬

‫اﻟﺮﻗﻢ اﻟﺴﺮي‬