‫ﻧﻤﻮﺫﺝ ﺭﻓﻊ ﺩﻋﻮﻯ‬

‫ﺭﻗﻢ ﺍﻟﺪﻋﻮﻯ‪CS-3418641/‬‬
‫ﺗﺎﺭﻳﺦ ﺍﻟﺪﻋﻮﻯ‪01/07/2024/‬‬
‫ﻋﺎﻣﻞ‬
‫ﺻﺎﺣﺐ ﺍﻟﻌﻤﻞ‬

‫ﺍﻟﻤﻮﻋﺪ‬
‫‪03/07/2024‬‬ ‫ﺍﻟﺘﺎﺭﻳﺦ‬ ‫‪ 10:00‬ﺹ ‪ 10:25‬ﺹ‬ ‫ﺍﻟﻮﻗﺖ‬
‫ﺗﺘﻢ ﺗﻌﺒﺌﺔ ﺍﻟﺤﻘﻮﻝ ﺃﺩﻧﺎﻩ ﻣﻦ ﻗﺒﻞ ﺍﻟﻤﺘﻘﺪﻡ ﻟﺮﻓﻊ ﺍﻟﺪﻋﻮﻯ )ﻋﺎﻣﻞ ‪/‬ﺍﻟﻤﻨﺸﺄﺓ‬
‫ﺗﻔﺎﺻﻴﻞ ﺍﻟﻤﻨﺸﺄﺓ‬ ‫ﻣﻌﻠﻮﻣﺎﺕ ﺍﻟﻌﺎﻣﻞ‬
‫ﻣﻌﻤﻞ ﺟﻠﻴﻤﻴﺪ ﺻﻮﻳﺎﻥ ﺍﻟﺪﻭﺳﺮﻱ‬ ‫ﺍﺳﻢ ﺍﻟﻤﻨﺸﺎﺓ‬ ‫‪MAHENDRA KUMAL‬‬ ‫ﺍﻻﺳﻢ ﺍﻟﻜﺎﻣﻞ‬
‫‪2515168793‬‬ ‫ﺭﻗﻢ ﺍﻟﻬﻮﻳﺔ ‪ /‬ﺍﻻﻗﺎﻣﺔ‬
‫ﻧﻴﺒﺎﻝ‬ ‫ﺍﻟﺠﻨﺴﻴﺔ‬
‫‪1011010696‬‬ ‫ﺭﻗﻢ ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ‬ ‫‪16/11/1989‬‬ ‫ﺗﺎﺭﻳﺦ ﺍﻟﻤﻴﻼﺩ)ﻣﻴﻼﺩﻱ(‬
‫‪,,‬ﺍﻟﻤﻨﻄﻘﺔ ﺍﻟﺸﺮﻗﻴﺔ‪,00,‬ﺍﻟﺪﻣﺎﻡ‪,‬‬ ‫ﻋﻨﻮﺍﻥ ﺍﻟﻌﺎﻣﻞ‬

‫ﺍﻟﺒﻴﺎﻧﺎﺕ ﺍﻟﻌﺎﻣﺔ‬
‫ﻧﺸﺎﻁ ﺍﻟﻤﻨﺸﺄﺓ‬ ‫ﺍﻹﻧﺠﻠﻴﺰﻳﺔ‬ ‫ﺍﻟﻠﻐﺔ‬
‫ﺟﻠﻴﻤﻴﺪ ﺻﻮﻳﺎﻥ ﺟﻠﻴﻤﻴﺪ ﺍﻟﺪﻭﺳﺮﻱ‬ ‫ﺍﻟﻤﻨﻄﻘﺔ ﺍﻟﺸﺮﻗﻴﺔ‬ ‫ﻣﻮﻗﻊ ﺍﻟﻌﻤﻞ‬
‫ﻣﺪﻳﺮ ﺍﻟﻤﻨﺸﺄﺓ‬
‫‪10/03/2021‬‬ ‫ﺗﺎﺭﻳﺦ ﺑﺪﺍﻳﺔ ﺍﻟﻌﻤﻞ‬
‫ﺍﻟﻌﻤﻞ ﺍﻷﺧﻴﺮ‬
‫ﺭﻗﻢ ﻫﺎﺗﻒ ﺍﻟﻤﻨﺸﺄﺓ‬ ‫‪01/07/2024‬‬ ‫ﺗﺎﺭﻳﺦ ﻧﻬﺎﻳﺔ ﺍﻟﻌﻤﻞ‬
‫ﻋﺎﻣﻞ‬ ‫ﺍﻟﻤﻬﻨﺔ‬
‫‪,,‬ﻣﻨﻄﻘﺔ ﺍﻟﺮﻳﺎﺽ‪,00,‬ﺍﻟﺮﻳﺎﺽ‪,‬‬ ‫ﻋﻨﻮﺍﻥ ﺍﻟﻤﻨﺸﺄﺓ‬
‫ﺍﻟﻤﻬﻨﺔ ﺍﻟﻔﻌﻠﻴﺔ‬
‫ﻳﺎﻧﺎﺕ ﺍﻟﻮﻛﻴﻞ‬ ‫‪1500‬‬ ‫ﺍﻟﺮﺍﺗﺐ‬
‫ﺻﺎﺣﺐ ﺍﻟﻌﻤﻞ‬
‫ﻣﺆﺳﺴﺔ‬ ‫ﺍﻟﻤﺪﻋﻰ ﻋﻠﻴﻪ‬ ‫‪0570426482‬‬ ‫ﺭﻗﻢ ﺍﻟﺠﻮﺍﻝ‬
‫ﺍﻟﺸﺮﻛﺔ‬
‫ﺍﺻﻴﻞ‬
‫ﻣﻤﺜﻞ ﺍﻟﻤﺪﻋﻰ ﻋﻠﻴﻪ‬ ‫ﺭﻗﻢ ﺍﺿﺎﻓﻲ‬
‫ﻭﻛﻴﻞ‬

‫ﻣﻮﺿﻮﻋﺎﺕ ﺍﻟﺪﻋﻮﻯ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﺃﺟﺮ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﻃﻠﺐ ﺃﺟﺮ ﻣﺘﺄﺧﺮ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﻣﻜﺎﻓﺄﺓ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﻃﻠﺐ ﻣﻜﺎﻓﺄﺓ ﻧﻬﺎﻳﺔ ﺧﺪﻣﺔ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﺗﻌﻮﻳﺾ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﺗﻌﻮﻳﺾ ﺁﺧﺮ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﺗﻌﻮﻳﺾ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﺗﻌﻮﻳﺾ ﺁﺧﺮ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﺇﺧﻼﺀ ﻃﺮﻑ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﺇﺧﻼﺀ ﻃﺮﻑ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﺗﻌﻮﻳﺾ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﺗﻌﻮﻳﺾ ﺁﺧﺮ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﺮﺋﻴﺴﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﻣﺴﺘﻨﺪﺍﺕ ﻭﻭﺛﺎﺋﻖ‬
‫ﺍﻟﻔﺌﺔ ﺍﻟﻔﺮﻋﻴﺔ ‪ :‬ﺩﻋﻮﻯ ﻃﻠﺐ ﺗﺴﻠﻴﻢ ﺍﻟﻮﺛﺎﺋﻖ‬

‫ﺍﺧﺮﻯ‬

‫ﺗﻔﺼﻴﻞ ﺍﻟﻄﻠﺒﺎﺕ‬
 ‫‪Non-malicious Prosecution Affidavit‬‬ ‫ﺇﻗﺮﺍﺭ ﺑﺄﻥ ﺍﻟﺪﻋﻮﻯ ﻏﻴﺮ ﻛﻴﺪﻳﺔ‬
‫ﻗﺮ ﺃﻧﺎ ﺑﺄﻧﻨﻲ ﻗﺮﺃﺕ ﻣﺎ ﻧﺼﺖ ﻋﻠﻴﻪ ﺍﻟﻤﺎﺩﺓ )ﺍﻟﺮﺍﺑﻌﺔ( ﻣﻦ ﻗﺮﺍﺭ ﻣﺠﻠﺲ‬
‫‪I hereby confirm that I have read the provision of article (4) of council of‬‬
‫ﺍﻟﻮﺯﺭﺍﺀ ﺭﻗﻢ )‪ (94‬ﻭﺗﺎﺭﻳﺦ ‪1406/04/25‬ﻫـ ﺍﻟﺬﻱ ﻳﻨﺺ ﺑﻤﺎ ﻳﻠﻲ‬
‫‪ministers Resolution No.(94) Date 25\04\1406 H, which provides for the following:‬‬
‫)ﻣﻦ ﺗﻘﺪﻡ ﺑﺪﻋﻮﻯ ﺧﺎﺻﺔ ﻭﺛﺒﺖ ﻟﻠﻤﺤﻜﻤﺔ ﻛﺬﺏ ﺍﻟﻤﺪﻋﻲ ﻓﻲ ﺩﻋﻮﺍﻩ‬
‫‪(If the applicant filed a private prosecution and proved to the plaintiff lied in his‬‬
‫ﻓﻠﻠﻘﺎﺿﻲ ﺃﻥ ﻳﻨﻈﺮ ﻓﻲ ﺗﻌﺰﻳﺮﻩ ﻭﻟﻠﻤﺪﻋﻰ ﻋﻠﻴﻪ ﺍﻟﻤﻄﺎﻟﺒﺔ ﺑﺎﻟﺘﻌﻮﻳﺾ‬
‫‪case, judge has right to penalize his/her case and defendant reserves right to claim‬‬
‫ﻋﻤﺎ ﻟﺤﻘﻪ ﻣﻦ ﺿﺮﺭ ﺑﺴﺒﺐ ﻫﺬﻩ ﺍﻟﺪﻋﻮﻯ(‬
‫) ‪compensation for damage incurred by him /her due to this case‬‬
‫ﻭﺑﻨﺎﺀ ﻋﻠﻴﻪ ﺃﻗﺮ ﺑﺄﻥ ﺩﻋﻮﺍﻱ ﺍﻟﺘﻲ ﺃﻧﺎ ﺑﺼﺪﺩ ﺗﻘﺪﻳﻤﻬﺎ ﻏﻴﺮ ﻛﻴﺪﻳﺔ‬
‫‪I hereby declare that my case is not malicious and if the case proves to be‬‬
‫ﻭﻓﻲ ﺣﺎﻝ ﺛﺒﺖ ﺃﻥ ﺍﻟﺪﻋﻮﻯ ﻛﻴﺪﻳﺔ ﻓﺈﻧﻨﻲ ﻟﺘﻄﺒﻴﻖ ﺍﻟﻤﺎﺩﺓ ﺍﻟﻤﺸﺎﺭ ﺇﻟﻴﻬﺎ‬
‫‪malicious, I shall be subject to the aforementioned article.‬‬
‫ﺃﻋﻼﻩ ﻓﻲ ﺣﻘﻲ‪.‬‬

‫ﺍﻟﺘﻮﻗﻴﻌﺎﺕ ﻭﺍﻻﻋﺘﻤﺎﺩﺍﺕ‬
‫ﺍﺳﻢ ﺍﻟﻤﺪﻋﻲ )ﻋﺎﻣﻞ‬
‫ـــ ـــ ‪ /‬ـــ ـــ ‪ /‬ـــ ـــ ـــ ـــ ﻫـ‬ ‫ﺍﻟﺘﺎﺭﻳﺦ‬ ‫ﺍﻟﺘﻮﻗﻴﻊ‬
‫‪ /‬ﺻﺎﺣﺐ ﻋﻤﻞ(‬
‫ﺍﺳﻢ ﺍﻟﻤﻮﻇﻒ‬
‫ـــ ـــ ‪ /‬ـــ ـــ ‪ /‬ـــ ـــ ـــ ـــ ﻫـ‬ ‫ﺍﻟﺘﺎﺭﻳﺦ‬ ‫ﺍﻟﺘﻮﻗﻴﻊ‬
‫ﺍﻟﺸﺎﻣﻞ‬
‫‪:‬ﺍﺭﺷﺎﺩﺍﺕ‬
‫ﻳﺠﺐ ﻋﻠﻰ ﻣﻘﺪﻡ ﺍﻟﺪﻋﻮﻯ ﺍﺭﻓﺎﻕ ﺍﻻﺗﻲ‪ :‬ـ‬
‫ﺻﻮﺭﺓ ﻣﻦ ﺍﻹﻗﺎﻣﺔ ‪/‬ﺍﻟﻬﻮﻳﺔ )ﺇﻥ ﻛﺎﻥ ﺍﻟﻤﺪﻋﻲ ﻋﺎﻣﻼً(‬
‫ﺻﻮﺭﺓ ﻣﻦ ﺍﻟﺴﺠﻞ ﺍﻟﺘﺠﺎﺭﻱ )ﺇﻥ ﻛﺎﻥ ﺍﻟﻤﺪﻋﻲ ﻣﻤﺜﻞ ﻣﻨﺸﺄﺓ(‬
‫ﻧﺴﺨﺔ ﻣﻦ ﻋﻘﺪ ﺍﻟﻌﻤﻞ‬
‫ﺻﻮﺭﺓ ﻣﻦ ﺍﻟﻤﺴﺘﻨﺪﺍﺕ ﺍﻟﺘﻲ ﺗﺜﺒﺖ ﺻﺤﺔ ﺍﻟﺪﻋﻮﻯ‬
‫ﺃﺻﻞ ﺍﻟﻮﻛﺎﻟﺔ ﺍﻟﺸﺮﻋﻴﺔ ﻟﻠﻮﻙ‬