1. ‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺠﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﻳﻤﻘﺮﺍﻃﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ‬
‫ﻭﺯﺍﺭﺓ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﻮﻃﻨﻴﺔ‬
‫ﺍﻟﺪﻳﻮﺍﻥ ﺍﻟﻮﻃﻨﻲ ﻟﻼﻣﺘﺤﺎﻧﺎﺕ ﻭﺍﻟﻤﺴﺎﺑﻘﺎﺕ‬
‫ﺍﺳﺘﻤﺎﺭﺓ ﻃﻠﺐ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻹﻟﻜﺘﺮﻭﻧﻴﺔ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺘﻌﻠﻴﻢ ﺍﻟﻤﺘﻮﺳﻂ ﺩﻭﺭﺓ :3102‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ :123‪achouri‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ :‪bonneroute987non‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ :527721‬ ‫ﺭﻣﺰ ﺍﻟﻤؤﺳﺴﺔ :35344‬
‫7388270531/‪20-10-2012,12:27:17/1350728837/ver‬‬ ‫ﺍﻟﻮﻻﻳــــﺔ:ﻋﻴﻦ ﺍﻟﺪﻓﻠﻰ‬
‫ﺍﻟﻤؤﺳﺴــﺔ:ﻣﺘﻮﺳﻄﺔ ﺑﻦ ﺯﺭﻫﻮﺩﺓ ﻋﻴﻦ ﺍﻟﺴﻠﻄﺎﻥ‬
‫ﺍﻟﻠﻐﺔ ﺍﻷﻣﺎﺯﻳﻐﻴﺔ:ﻻ ﻟﺴﺖ ﻣﻌﻨﻲ ﺑﺎﻷﻣﺎﺯﻳﻐﻴﺔ‬
‫ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﻤﻮﺳﻴﻘﻴﺔ:ﻧﻌﻢ ﻣﻌﻨﻲ ﺑﺎﻟﺘﺮﺑﻴﺔ ﺍﻟﻤﻮﺳﻴﻘﻴﺔ‬
‫ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﻔﻨﻴﺔ ﻭﺍﻟﺘﺸﻜﻴﻠﻴﺔ:ﻻ ﻟﺴﺖ ﻣﻌﻨﻲ ﺑﺎﻟﺘﺮﺑﻴﺔ ﺍﻟﻔﻨﻴﺔ ﻭﺍﻟﺘﺸﻜﻴﻠﻴﺔ‬
‫*‬ ‫1‬ ‫4‬ ‫4‬ ‫0‬ ‫1‬ ‫2‬ ‫7‬ ‫7‬ ‫2‬ ‫5‬ ‫*‬
‫ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ:ﻛﻔء‬
‫ﺍﻟﻠﻘﺐ :ﺑﻮﻛﺮﻭﺵ‬
‫ﺍﻻﺳﻢ :ﻋﺒﺪ ﺍﻟﺮﺣﻤﺎﻥ‬
‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ :12-ﺃﻛﺘﻮﺑﺮ-5991ﺑـ :ﻣﻠﻴﺎﻧﺔﻭﻻﻳﺔ :ﻋﻴﻦ ﺍﻟﺪﻓﻠﻰ‬
‫ﺍﻟﺠﻨﺲ :ﺫﻛﺮ‬
‫ﺍﻟﺠﻨﺴﻴﺔ :ﺟﺰﺍﺋﺮﻳﺔ‬
‫ﺍﻟﻬﺎﺗﻒ :830712677‬
‫ﺍﻟﻌﻨﻮﺍﻥ :ﻋﻴﻦ ﺍﻟﺴﻠﻄﺎﻥ‬
‫: ‪email‬‬
‫ﻗﺮﺍﺭ ﺍﻟﻄﺒﻴﺐ ﻻﺟﺘﻴﺎﺯ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‬
‫ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺃﺩﻧﺎﻩ: ....................................................................................................................................................... ﺃﺷﻬﺪ ﺃﻥ ﺍﻟﻤﺘﺮﺷﺢ )ﺓ( ﺍﻟﻤﺬﻛﻮﺭ )ﺓ( ﺇﺳﻤﻪ )ﻫﺎ( ﺃﻋﻼﻩ.‬
‫)ﺳﺠﻞ ﺍﻟﻌﺒﺎﺭﺓ ﻛﻔء ﺃﻭ ﻏﻴﺮ ﻛﻔء( ﻻﺟﺘﻴﺎﺯ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‬
‫ﺣﺮﺭ ﺑـ:........................................ﻔﻲ:..................................‬
‫ﻫﺎﻡ ﺟﺪﺍ:‬
‫ﺇﻣﻀﺎﺀ ﻭﺧﺘﻢ ﺍﻟﻄﺒﻴﺐ‬ ‫ﺗﻤﻸ ﻫﺬﻩ ﺍﻟﺒﻄﺎﻗﺔ ﺇﺟﺒﺎﺭﻳﺎ ﻣﻦ ﻃﺮﻑ ﻃﺒﻴﺐ ﺍﻟﺼﺤﺔ ﺍﻟﻤﺪﺭﺳﻴﺔ‬
‫ﺑﺎﻟﻨﺴﺒﺔ ﻟﻠﻤﺘﻤﺪﺭﺳﻴﻦ ﻭﻃﺒﻴﺐ ﻣﺤﻠﻒ ﺑﺎﻟﻨﺴﺒﺔ ﻟﻸﺣﺮﺍﺭ.‬
‫ﻳﺸﻬﺪ ﺍﻟﻤﺘﺮﺷﺢ ﺃﻥ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺴﺠﻠﺔ ﻋﻠﻰ ﻫﺬﻩ ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺍﺳﻔﻠﻪ ﺃﺷﻬﺪ ﺃﻥ ﻫﺬﺍ )ﻩ( ﺍﻟﻤﺘﺮﺷﺢ )ﺓ( )ﺕ( ﻳﺰﺍﻭﻝ ﺩﺭﺍﺳﺘﻪ )ﻫﺎ( ﻓﻲ ﺍﻟﺴﻨﺔ ﺍﻟﺮﺍﺑﻌﺔ ﻣﺘﻮﺳﻂ ﺑﺎﻟﻤؤﺳﺴﺔ ﻭﺃؤﻛﺪ ﺃﻥ‬
‫ﺍﻻﺳﺘﻤﺎﺭﺓ ﺻﺤﻴﺤﺔ ﻭﻳﺘﺤﻤﻞ ﺍﻟﻤﺴؤﻭﻟﻴﺔ ﻛﺎﻣﻠﺔ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺴﺠﻠﺔ ﻋﻠﻰ ﻫﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻗﺪ ﺭﺍﻗﺒﺘﻬﺎ..‬
‫ﻓﻲ ﺣﺎﻟﺔ ﻭﺟﻮﺩ ﺃﺧﻄﺎﺀ‬
‫ﺣﺮﺭ ﺑـ:........................................ﻔﻲ:..................................‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬ ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﺘﺮﺷﺢ:‬
‫7388270531/‪20-10-2012,12:27:17/1350728837/ver‬‬
‫ﻭﺻﻞ ﺍﺳﺘﻼﻡ :ﻳﺸﻬﺪ ﻣﺪﻳﺮ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ ﺃﻥ‬
‫ﺍﻟﻤﺘﺮﺷﺤ)ﺔ(....................................................................... ﻗﺪ ﺳﻠﻢ ﻣﻠﻒ ﺍﻟﺘﺴﺠﻴﻞ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺘﻌﻠﻴﻢ ﺍﻟﻤﺘﻮﺳﻂ ﺩﻭﺭﺓ:3102‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ :123‪achouri‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ :‪bonneroute987non‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ :527721‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ‬ ‫ﺣﺮﺭ ﺑـ : ................................................ﻓﻲ:........................................‬
‫ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬