‫اﻟـﺠﻤﮭﻮرﯾـــﺔ اﻟـﺠﺰاﺋﺮﯾــــﺔ اﻟـﺪﯾﻤﻘﺮاﻃﯿــــﺔ‬

‫اﻟـﺸﻌﺒﯿـــــﺔ‬

‫ﺷﮭﺎدة ﻃﺒﯿﺔ ﻋﺎﻣﺔ‬

‫اﻟﺣﻛﯾم‪...........................................................................................................:‬‬ ‫أﻧﺎ اﻟﻣﻣﺿﻲ أﺳﻔﻠﮫ‬
‫ﺑﻌد ﻓﺣص اﻟﺳﯾـد)ة(‪.........................................................................:‬‬
‫اﻟﻌﻣـــر‪...........................................:‬‬
‫ﻣﺗرﺷﺢ)ة( ﻟﻌﻣـل‪...................................................................................................................:‬‬
‫اﻟﺳﺎﻛــن)ة( ﺑــ ‪.............................................................................................................................:‬‬

‫أﺷﮭـد ﺑﺄﻧﮫ ﺳﻠﯾـم ﻣن ﻛل ﻣرض أو ﻋطب ﯾﺗﻧﺎﻓـﻰ ﻣﻊ اﻟﻌﻣل اﻟﻣطﻠــوب‪.‬‬

‫‪.......................................‬‬ ‫ﺣـرر ﻓــﻲ ‪:‬‬

‫إﻣﺿـﺎء اﻟطﺑﯾب‬

‫ﺷﮭﺎدة ﻃﺒﯿﺔ ﺧﺎﺻــﺔ‬

‫أﻧﺎ اﻟﻣﻣﺿﻲ أﺳﻔﻠﮫ‬
‫اﻟﺣﻛﯾم‪.............................................................................................................................:‬‬
‫ﺑﻌد ﻓﺣص اﻟﺳﯾـد)ة(‪.........................................................................:‬‬
‫اﻟﻌﻣـــر‪...........................................:‬‬
‫ﻣﺗرﺷﺢ)ة( ﻟﻌﻣـل‪......................................................................................................................:‬‬
‫اﻟﺳﺎﻛــن)ة( ﺑــ ‪..............................................................................................................................:‬‬
‫أﺷﮭـد ﺑﺄﻧﮫ ﻣﻌﺎﻓﻰ ﻧﮭﺎﺋﯾﺎ ﻣن ﻣرض اﻟﺳــل أو أي ﻣرض ﺻدري ﻣﺷﺎﺑـــﮫ‪.‬‬
‫‪.......................................‬‬ ‫ﺣـرر ﻓــﻲ ‪:‬‬

‫إﻣﺿـﺎء اﻟطﺑﯾب‬