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‫ﺑﺴﻤﻪ ﺗﻌﺎﻟﻲ‬ ‫ﻧﻤﺎﻳﻨﺪﮔﻲ ﺟﻤﻬﻮﺭﻱ ﺍﺳﻼﻣﻲ ﺍﻳﺮﺍﻥ ﻛﻮﺍﻻﻻﻣﭙﻮﺭ‬

‫ﭘﺮﺳﺸﻨﺎﻣﻪ ﺩﺭﺧﻮﺍﺳﺖ ﺛﺒﺖ ﺍﺯﺩﻭﺍﺝ‬ ‫ﺧﻮﺍﻫﺸﻤﻨﺪ ﺍﺳﺖ ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻣﺪﺍﺭﻙ ﺿﻤﻴﻤﻪ ﻧﺴﺒﺖ ﺑﻪ ﺛﺒﺖ ﺍﺯﻭﺍﺝ ﺭﺳﻤﻲ‬ ‫ﺍﻳﻨﺠﺎﻧﺒﺎﻥ ﺑﺎ ﻣﺸﺨﺼﺎﺕ ﺫﻳﻞ ﺍﻗﺪﺍﻣﺎﺕ ﻻﺯﻡ ﻣﻌﻤﻮﻝ ﻧﻤﺎﻳﻨﺪ‪:‬‬

‫ﺯﻭﺝ‪) :‬ﺷﻮﻫﺮ(‬

‫ﻧﺎﻡ‬ ‫ﺷﻤﺎﺭﻩ ﺷﻨﺎﺳﻨﺎﻣﻪ‬ ‫ﻣﺘﻮﻟﺪ ‪....../....../.....‬‬

‫ﺯﻭﺟﻪ‪) :‬ﺯﻥ(‬

‫ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ‬ ‫ﻣﺤﻞ ﺻﺪﻭﺭ‪ :‬ﺣﻮﺯﻩ‬ ‫ﻣﺤﻞ ﺗﻮﻟﺪ‬

‫ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ‬ ‫ﻧﺎﻡ‬ ‫ﻣﺤﻞ ﺻﺪﻭﺭ‪ :‬ﺣﻮﺯﻩ‬ ‫ﺷﻤﺎﺭﻩ ﺷﻨﺎﺳﻨﺎﻣﻪ‬ ‫ﻣﺤﻞ ﺗﻮﻟﺪ‬ ‫ﻣﺘﻮﻟﺪ ‪......./....../....‬‬ ‫ﻧﺸﺎﻧﻲ ﻭ ﺷﻤﺎﺭﻩ ﺗﻠﻔﻦ ﻣﺤﻞ ﺳﻜﻮﻧﺖ‪:‬‬

‫ﺍﻣﻀﺎ ﺯﻭﺝ‬

‫ﺍﻣﻀﺎ ﺯﻭﺟﻪ‬

‫ﻓﺮﺯﻧﺪ‬ ‫ﺷﻬﺮ‬

‫ﻓﺮﺯﻧﺪ‬ ‫ﺷﻬﺮ‬

‫ﺗﺎﺭﻳﺦ‬


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