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‫ﺣﺰب اﻷﺻﺎﻟﺔ‬

‫‪‬‬ ‫رﻗﻢ اﻟﻌﻀﻮﻳﺔ ﺑﺎﻟﺤﺰب‬

‫اﻟﺒﻴﺎﻧﺎت اﻟﺸﺨﺼﻴﺔ‬ ‫إﺳﻢ اﻟﺸﻬﺮة‬

‫اﻻﺳﻢ‬ ‫اﻟﻨﻮع‬

‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬

‫اﻧﺜﻲ‬

‫ذآﺮ‬

‫ﺻﻮرة‬ ‫ﺷﺨﺼﻴﺔ‬

‫ﻣﺤﻞ اﻟﻤﻴﻼد ‪ :‬ﻣﺤﺎﻓﻈﺔ‬

‫ﻣﺤﻞ اﻹﻗﺎﻣﺔ‬

‫ﻣﺤﺎﻓﻈﺔ‬ ‫اﺳﻢ اﻟﺠﻬﺔ‬

‫اﻟﻤﺆهﻞ‬ ‫ﻃﺒﻴﻌﺔ اﻟﻌﻤﻞ‬

‫ﻃﺒﻴﺐ‬

‫ﻣﻬﻨﺪس‬

‫ﺻﻴﺪﻟﻲ‬

‫ﺟﻬﺔ اﻟﻌﻤﻞ‬

‫ﻗﺎﻧﻮﻧﻲ‬

‫ﺗﺠﺎري‬ ‫اﻟﺒﻄﺎﻗﺔ‬

‫اﻟﻜﻮد‬

‫رﻗﻢ اﻟﻬﺎﺗﻒ اﻟﻤﻨﺰﻟﻲ‬

‫ﺷﺨﺼﻴﺔ‬

‫ﺁﺧﺮي‬ ‫اﻟﺮﻗﻢ اﻟﻘﻮﻣﻲ‬

‫ﻋﺎﺋﻠﻴﺔ‬

‫رﻗﻢ ﺁﺧﺮ‬

‫رﻗﻢ اﻟﻤﺤﻤﻮل‬

‫اﻟﺒﺮﻳﺪ اﻹﻟﻜﺘﺮوﻧﻲ‬ ‫اﻟﺒﻴﺎﻧﺎت اﻟﻌﺎﺋﻠﻴﺔ‬ ‫إﺳﻢ اﻟﺰوﺟﺔ‬

‫ﻋﺪد اﻻوﻻد‬

‫اﻟﺠﻨﺴﻴﺔ‬

‫اﻟﻤﺆهﻞ‬

‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‬

‫اﺳﻢ اﻟﺠﻬﺔ‬

‫ﻃﺒﻴﻌﺔ اﻟﻌﻤﻞ‬

‫ﻃﺒﻴﺐ‬

‫ﻣﻬﻨﺪس‬

‫ﺻﻴﺪﻟﻲ‬

‫ﺗﺠﺎري‬

‫ﻗﺎﻧﻮﻧﻲ‬

‫ﺁﺧﺮي‬

‫ﻓﻲ ﺣﺎﻟﺔ ﺗﻌﺪد اﻟﺰوﺟﺎت ﻳﺮﺟﻲ ﻣﻠﺊ اﺳﺘﻤﺎرة ﺁﺧﺮي وإرﻓﺎﻗﻬﺎ ﺑﺎﻻﺳﺘﻨﻤﺎرﻩ‬

‫اﻟﺨﺒﺮات اﻟﺴﺎﺑﻘﻪ‬

‫ﻃﺮق ﺗﺪﻋﻴﻢ اﻟﺤﺰب‬ ‫ﻣﺎﻟﻲ‬

‫ﻓﻜﺮي‬

‫ﻋﻴﻨﻲ‬

‫ﺷﺨﺼﻲ‬

‫ﺁﺧﺮي‬

‫آﻴﻒ‬

‫ﺑﻴﺎﻧﺎت ﺁﺧﺮي‬ ‫‪------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------‬‬‫‪------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------‬‬‫‪-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------‬‬

‫ﻃﻠﺐ إﻧﻀﻤﺎم‬ ‫اﻟﺴﻴﺪ اﻻﺳﺘﺎذ ‪ /‬رﺋﻴﺲ ﺣﺰب اﻷﺻﺎﻟﺔ‬ ‫ﺗﺤﻴﺔ ﻃﻴﺒﺔ وﺑﻌﺪ‬ ‫ارﺟﻮ ﻗﺒﻮل اﻧﻀﻤﺎﻣﻲ ﻟﻠﺤﺰب آﻌﻀﻮ ) ﻋﺎﻣﻞ ‪ /‬ﻣﻨﺘﺴﺐ ( ‪ ،‬واﻧﺎ ﻣﺴﺌﻮل ﻣﺴﺌﻮﻟﻴﺔ ﻗﺎﻧﻮﻧﻴﺔ آﺎﻣﻠﺔ ﻋﻦ ﺻﺤﺔ هﺬﻩ اﻟﺒﻴﺎﻧﺎت وﻋﻦ ﻣﻮاﻓﺎﺗﻜﻢ ﺑﺄي ﺗﻐﻴﺮ ﻳﻄﺮأ ﻋﻠﻴﻬﺎ ‪.‬‬ ‫ﺗﺤﺮﻳﺮًا ﻓﻲ ‪:‬‬

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‫‪ 8‬ش اﺣﻤﺪ اﻟﺰﻣﺮ ‪ -‬اﻣﺎم ﺷﺮآﺔ اﻧﺒﻲ‬

‫وﺗﻔﻀﻠﻮا ﺑﻘﺒﻮل ﻓﺎﺋﻖ اﻻﺣﺘﺮام‬

‫اﻟﺘﻮﻗﻴﻊ‬

‫‪---------------------------‬‬‫ﺗﻠﻴﻔﻮن ‪ 8‬ﺧﻄﻮط‬

‫‪1/2/3/4/5/7/8/9‬‬

‫‪666‬‬

‫‪33‬‬

‫‪140‬‬


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