‫اﻟﻌﻤﺮ‪40 :‬‬

‫اﻟﻤﻮﻗﻊ‪belimour :‬‬

‫]‪[b‬ﺗﺼﺮﯾﺢ ﺷﺮﻓﻲ ﺑﻌﺪم اﻣﺘﻼك ﺟﻮاز ﺳﻔﺮ ]‪b/‬‬

‫[أﻧﺎ اﻟﻤﻤﻀﻲ)ة( أﺳﻔﻠﮫ اﻟﺴﯿﺪ )ة( ‪:‬‬
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‫اﻟﻤﻮﻟﻮد )ة( ﺑﺘﺎرﯾﺦ ‪.................................................. :‬‬
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‫اﻟﺤﺎﻣﻞ )ﺑﻄﺎﻗﺔ اﻟﺘﻌﺮﯾﻒ اﻟﻮﻃﻨﯿﺔ( أو )رﺧﺼﺔ ﺳﯿﺎﻗﺔ( رﻗﻢ ‪:‬‬
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‫اﻟﺼﺎدرة ﺑﺘﺎرﯾﺦ ‪.................................................. :‬‬
‫‪ ............................‬ﻋﻦ داﺋﺮة ‪:‬‬
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‫اﻟﺴﺎﻛﻦ )ة( ﺑـ ‪.................................................. :‬‬
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‫أﺻﺮح ﺑﺸﺮﻓﻲ ﺑﺄﻧﻲ ﻻأﻣﻠﻚ ﺟﻮاز ﺳﻔﺮ ﻣﻦ ﻗﺒﻞ‬

‫ﻓﻲ ‪:‬‬
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‫إﻣﻀﺎء اﻟﻤﻌﻨﻲ ﺑﺎﻷﻣﺮ ﻣﺼﺎدﻗﺔ اﻟﺒﻠﺪﯾﺔ‬