‫ﺗﺼﺮﻳﺢ ﺑﺎﻟﺸﺮﻑ‬

‫ﻳﺘﻌﻠﻖ ﺑﺘﺴﺠﻴﻞ ﺩﺭﺍﺟﺔ ﻧﺎﺭﻳﺔ ﺃﻭ ﺩﺭﺍﺟﺔ ﺛﻼﺛﻴﺔ ﺑﻤﺤﺮﻙ ﺃﻭ ﺩﺭﺟﺔ ﺭﺑﺎﻋﻴﺔ‬

‫ﺍﻟﻌﺠﻼﺕ ﺛﻘﻴﻠﺔ ﺑﻤﺤﺮﻙ‬

‫ﺃﻧﺎ ﺍﻟﻤﻮﻗﻊ)ﺓ( ﺃﺳﻔﻠﺔ ﺍﻟﺴﻴﺪ)ﺓ(‪:‬‬

‫ﺍﻻﺳﻢ ﺍﻟﻌﺎﺋﻠـــــﻲ‪............................................................................................... :‬‬
‫ﺍﻻﺳﻢ ﺍﻟﺸﺨﺼﻲ‪............................................................................................... :‬‬
‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻻﺯﺩﻳﺎﺩ‪........................................................................................ :‬‬
‫ﺍﻟﺤﺎﻣﻞ)ﺓ( ﻟﺒﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ﺍﻭ ﺑﻄﺎﻗﺔ ﺍﻹﻗﺎﻣﺔ ﺭﻗﻢ‪......................................................... :‬‬
‫ﺍﻟﻘﺎﻃﻦ)ﺓ( ﺑــــ‪................................................................................................. :‬‬
‫‪....................................................................................................................‬‬

‫ﺃﺻﺮﺡ ﺃﻧﻲ ﺃﻣﻠﻚ ﻣﻨﺬ ﺗﺎﺭﻳﺦ‪............................................................................... :‬‬

‫ﺩﺭﺍﺟﺔ ﻧﺎﺭﻳﺔ ﺃﻭ ﺩﺭﺍﺟﺔ ﺛﻼﺛﻴﺔ ﺑﻤﺤﺮﻙ ﺃﻭ ﺩﺭﺟﺔ ﺭﺑﺎﻋﻴﺔ ﺍﻟﻌﺠﻼﺕ ﺛﻘﻴﻠﺔ ﺑﻤﺤﺮﻙ ﺫﺍﺕ ﺍﻟﺨﺼﺎﺋﺺ‬
‫ﺍﻟﺜﻘﻨﻴﺔ ﺍﻟﺘﺎﻟﻴﺔ‪:‬‬
‫ﺍﻟﻌﻼﻣﺔ )‪......................................................................................... :(Marque‬‬
‫ﺍﻟﺼﻨـــــــــــــــــــﻒ‪........................................................................................ :‬‬
‫ﺍﻟﻨـــــــــــــــــــــﻮﻉ‪......................................................................................... :‬‬
‫ﺣﺠﻢ ﺃﺳﻄﻮﺍﻧﺘــــــﻬﺎ‪......................................................................................... :‬‬
‫ﺭﻗﻢ ﺍﻹﻃﺎﺭ ﺍﻟﺤﺪﻳﺪﻱ‪........................................................................................ :‬‬
‫ﺗﺎﺭﻳﺦ ﺃﻭﻝ ﺷﺮﻭﻉ ﻓﻲ ﺍﻻﺳﺘﺨﺪﺍﻡ‪......................................................................... :‬‬
‫ﻛﻤﺎ ﺃﺃﻛﺪ ﺻﺤﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻮﺍﺭﺩﺓ ﻓﻲ ﻫﺬﺍ ﺍﻟﺘﺼﺮﻳﺢ ﻭﺃﺗﺤﻤﻞ ﻛﺎﻣﻞ ﺍﻟﻤﺴﺆﻭﻟﻴﺔ ﺇﺫﺍ ﺛﺒﺖ ﺍﻟﻌﻜﺲ ﺃﻭ‬
‫ﻣﺎ ﺧﺎﻟﻒ ﺍﻟﻘﻮﺍﻧﻴﻦ ﻭﺍﻷﻧﻈﻤﺔ ﺍﻟﺠﺎﺭﻱ ﺑﻬﺎ ﺍﻟﻌﻤﻞ ﻓﻲ ﻫﺬﺍ ﺍﻟﺸﺄﻥ‪.‬‬
‫ﺣﺮﺭ ﻓﻲ ‪............................. :‬ﺑﺘﺎﺭﻳﺦ ‪.................................. :‬‬
‫ﺇﻣﻀﺎﺀ ﺍﻟﻤﺼﺮﺡ ﻣﺼﺎﺩﻕ ﻋﻠﻴﻪ‬