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‫الصندوق الوطني‬

‫للضمان االجتماعي‬
‫مكتب‬
‫رقم الوارد ‪:‬‬
‫التاريخ ‪:‬‬
‫  _____________‬

‫   ‬ ‫ ‪ :‬‬

‫ ‪___ / ________________ :    ______________________________ :‬‬


‫   ‪____ ____ ______ :   !" _______________________________ :‬‬
‫(' ‪:‬‬ ‫‪: # $% & !%‬‬
‫‪_____ / __ / __  __________)1‬‬ ‫‪_____ / __ / __  ___________ : '%‬‬
‫‪_____ / __ / __  __________)2‬‬ ‫ ‪_____ / __ / __  ___________ :‬‬
‫‪_____ / __ / __  __________)3‬‬ ‫‪_____ / __ / __  ___________ : *+‬‬
‫‪-  # .  / _______ 0 &  _____ / ___ / ___ 1 !, ' * !* 2  *,‬‬
‫‪ 2 * 3 2 0‬‬
‫‪# * / 4 ______________ % - &+( 6‬‬ ‫(*! ‪5 0‬‬
‫‪. 84  &,9 !   + *  ! ";5  / ____________ # !$(!,  !2‬‬
‫‪_____________ : < != ______________ : 2> ____________ : ?!  : #  # #‬‬
‫‪___ ___________ : @!A _______________ :   ____________ : 83‬‬
‫‪_____________ : < != ______________ : 2> ____________ : ?!  : # #% #‬‬
‫‪___ ___________ : @!A _______________ :   ____________ : 83‬‬

‫‪/ 0  (  ! ,2, 3 5 $‬‬ ‫ ‪:‬‬


‫‪#  D%‬‬ ‫* => ‪,! C !,-‬‬

‫قرار رئيس المكتب رقم ____ تاريخ ___‪_____/___/‬‬ ‫تقرير المحقّق ‪:‬‬
‫‪_____________ # !$(   3 2 D‬‬ ‫ ‪_______ # !$(   2  ,!* F‬‬
‫‪_____________ # !$( @ 2 0 D‬‬ ‫ ‪_______ # !$( @ 2  ,3% F‬‬
‫‪: ! !,E _____/___/___ # " !,‬‬ ‫‪: ! !,E‬‬
‫‪_________________________________ )1‬‬ ‫‪_________________________________ )1‬‬
‫‪_________________________________ )2‬‬ ‫‪_________________________________ )2‬‬
‫‪_________________________________ )3‬‬ ‫‪_________________________________ )3‬‬
‫!      ‬ ‫‪52  D 0!G‬‬

‫‪CNSS 485‬‬

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