‫اﶺـﻬﻮرﻳﺔ اﳉﺰا ﺮﻳﺔ ا ﳝﻘﺮاﻃﻴﺔ اﻟﺸﻌﺒ ﺔ‬

‫وزارة اﻟﺘﻌﻠﲓ اﻟﻌﺎﱄ واﻟﺒﺤﺚ اﻟﻌﻠﻤﻲ‬

‫ﺟ ﺎﻣﻌ ﺔ ﺳﻌ( ﺪة د‪ .‬ﻣـﻮﻻي اﻟﻄ ﺎﻫـﺮ‬
‫ﻧﻴﺎﺑﺔ ﻣﺪ‪4‬ﺮﻳﺔ اﳉﺎﻣﻌﺔ ‪3‬ﻠﺒﻴﺪاﻏﻮﺟ ﺎ‬

‫ﺗﺼﺮﻳﺢ ﺷﺮﻓﻲ‬
‫‪........................................................................................:‬‬ ‫أﻧﺎ اﳌﻤﻀﻲ أﺳﻔﻠﻪ اﻟﻄﺎﻟﺐ )ة(‬
‫‪..............................................‬‬ ‫اﳌﻮﻟﻮد )ة( ﺑﺘﺎرﻳﺦ ‪.........................................................:‬ﺑـ ـ‪:‬‬
‫‪..................................................‬‬ ‫اﳊﺎﻣﻞ ﻟﺒﻄﺎﻗﺔ اﻟﺘﻌﺮﻳﻒ اﻟﻮﻃﻨﻴﺔ ‪ /‬رﺧﺼﺔ ﺳﻴﺎﻗﺔ ﲢﺖ رﻗﻢ ‪:‬‬
‫‪.............................‬‬ ‫اﻟﺼﺎدرة ﻋﻦ داﺋﺮة ‪ ...........................:‬وﻻﻳﺔ ‪ ..........................:‬ﺑﺘﺎرﻳﺦ ‪:‬‬
‫‪....................................‬‬ ‫اﳌﺴﺠﻞ)ة( ﰲ اﻟﺴﻨﺔ‪.............................................:‬ﻟﻠﺴﻨﺔ اﳉﺎﻣﻌﻴﺔ‪:‬‬
‫ﺑﻘﺴﻢ‪..............................................................................................................................:‬‬

‫‪............................................................................................................................‬‬ ‫ﻣﻴﺪان‪:‬‬
‫‪.............................................................................................................................‬‬ ‫ﺷﻌﺒﺔ‪:‬‬
‫‪.........................................................................................................................‬‬ ‫ﲣﺼﺺ‪:‬‬

‫‪.........................‬‬ ‫أﺻﺮح ﺑﺸﺮﰲ أﱐ ﺳﺤﺒﺖ ﻛﺸﻒ اﻟﻨﻘﺎط اﻷﺻﻠﻲ ﻟﺸﻬﺎدة اﻟﺒﻜﺎﻟﻮرﻳﺎ‪ ،‬دورة‪:‬‬
‫اﻟﺼﺎدر ﺑﺘﺎرﻳﺦ‪ ..............................................:‬ﲢﺖ رﻗﻢ ‪................................................:‬‬

‫ﻣﻦ‪ :‬ﻣﺼﻠﺤﺔ اﻟﺘﻌﻠﻴﻢ‪ ،‬اﻟﺘﺪارﻳﺐ و اﻟﺘﻘﻴﻴﻢ ﻟﻨﻴﺎﺑﺔ اﳉﺎﻣﻌﺔ ﻟﻠﺒﻴﺪاﻏﻮﺟﻴﺎ‪.‬‬

‫إﻣﻀﺎء اﻟﻤﻌﻨﻲ ﺑﺎﻷﻣﺮ‬ ‫اﻟﻤﺼﺎدﻗﺔ ﻣﻦ ﻃﺮف اﻟﺒﻠﺪﻳﺔ‬