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‫اﻟﺠﻤﮭﻮرﯾﺔ اﻟﺠﺰاﺋﺮﯾﺔ اﻟﺪﯾﻤﻘﺮاطﯿﺔ اﻟﺸﻌﺒﯿﺔ‬

‫وزارة اﻟﺘﻜﻮﯾﻦ و اﻟﺘﻌﻠﯿﻢ اﻟﻤﮭﻨﯿﯿﻦ‬


‫ﻣﺪرﺳﺔ ﻣﯿﺪاف – ﻣﻌﺘﻤﺪة ﻣﻦ اﻟﺪوﻟﺔ‬
‫رﻗﻢ ‪ 13‬ﺣﻲ ﻗﺮﻣﺎح ‪ -‬طﺮﯾﻖ ﻓﻮﻛﺔ ‪ -‬اﻟﻘﻠﯿﻌﺔ‬
‫ﻣﺪﯾﻨﺔ اﻟﻘﻠﯿﻌﺔ ‪ -‬ﺑﺎﻟﻘﺮب ﻣﻦ دار اﻟﺜﻘﺎﻓﺔ‬
‫ھﺎﺗﻒ اﻹدارة ‪0696115462 - 024381419 – 024381418 :‬‬
‫ھﺎﺗﻒ اﻟﻤﺪﯾﺮ ‪069611540 :‬‬
‫اﻟﻔﺎﻛﺲ ‪024381420 :‬‬
‫رﻗﻢ اﻹﻋﺘﻤﺎد ‪ 516/1062 :‬ﺑﺘﺎرﯾﺦ ‪ 19‬ﻣﺎرس ‪2000‬‬

‫– ﺷﮭﺎدة ﺗﺄھﯾﻠﯾﺔ‬ ‫اﺳﺗﻣﺎرة اﻟﺗﺳﺟﯾل‬


‫‪............................................................................................................................. :‬‬ ‫اﻹﺳم‬
‫‪.............................................................................................................................‬‬ ‫اﻟﻠﻘب ‪:‬‬
‫‪...............................................................................................................‬‬ ‫اﻟﻌﻧوان اﻟﻛﺎﻣل ‪:‬‬
‫‪............................................. .............................................................................................‬‬

‫‪...............................................................................................................‬‬‫رﻗم اﻟﮭﺎﺗف )‪(1‬‬


‫رﻗم اﻟﮭﺎﺗف )‪............................................................................................................. : (2‬‬

‫‪.........................................................................................................‬‬ ‫اﻟﻣﺳﺗوى اﻟدراﺳﻲ ‪:‬‬


‫‪.......................................................................................................‬‬ ‫اﻟﺗﺧﺻص اﻟﻣطﻠوب ‪:‬‬
‫‪................................................................................................................... :‬‬ ‫ﺗﺎرﯾﺦ اﻟﻣﯾﻼد‬
‫ﻣﻛﺎن اﻟﻣﯾﻼد ‪) ................................................................................ :‬اﻟﺑﻠدﯾﺔ و اﻟوﻻﯾﺔ(‬
‫‪................................................................................‬‬ ‫اﻟﺟﻧﺳﯾﺔ اﻟﺣﺎﻟﯾﺔ ‪:‬‬
‫ﻓﺗرة اﻟدروس ‪  :‬ﺻﺑﺎﺣﯾﺔ )‪ 8‬اﻟﻰ ‪  (17‬ﻣﺳﺎﺋﯾﺔ )‪ 17‬اﻟﻰ ‪  (20‬أﯾﺎم اﻟﺟﻣﻌﺔ و اﻟﺳﺑت‬
‫اﻟرﺟﺎء ﻣﻸ ھذه اﻻﺳﺗﻣﺎرة ﻣﻊ ﺗدﻗﯾق اﻟﻣﻌﻠوﻣﺎت اﻟﺗﻲ ﺗﺗﺿﻣﻧﮭﺎ‪ .‬ﺗودع ھذه اﻻﺳﺗﻣﺎرة ﻣﻊ‬
‫اﻟوﺛﺎﺋق اﻟﻣطﻠوﺑﺔ ﻛﺎﻣﻠﺔ أﻣﺎم إدارة اﻟﻣدرﺳﺔ‪.‬‬
‫‪..............................................:‬‬ ‫اﻟﺗﺎرﯾﺦ‬
‫اﻹﻣﺿﺎء‬