ÇáÝÕá ÇáËÇáË
ÖÚí ÚáÇãÉ ( ) Ãæ ÚáÇãÉ ( )
ãä ÂÏÇÈ ÇáÕæã ÊÚÌíá ÇáÓÍæÑ æÊÃÎíÑ ÇáÝØæÑ ( )
ÇáÕæã íÌÚá ÇáÃÛäíÇÁ íÔÚÑæä ÈÍÇÌÉ ÇáÝÞÑÇÁ ( )
Õæä ÇááÓÇä Úä ÇáßáÇã ÇáÓíÁ íßæä Ýí ÔåÑ ÑãÖÇä ÝÞØ ( )
ÇáÅßËÇÑ ãä ÊáÇæÉ ÇáÞÑÂä ãä ÝÖÇÆá ÇáÕæã( )
ÇáÕæã ÓÈÈ áãÛÝÑÉ ÇáÐäæÈ ( )

áæäí ÝÖÇÆá ÇáÕæã ÈÇááæä ÇáÃÍãÑ æÇáÂÏÇÈ ÈÇááæä ÇáÃÎÖÑ

ÊÞÏíã ÇáÚæä æÇáãÓÇÚÏÉ ááãÍÊÇÌíä
Þæá : ÐåÈ ÇáÙãà æÇÈÊáÊ ÇáÚÑæÞ æËÈÊ ÇáÃÌÑ
ÇáÅßËÇÑ ãä ÇáÕÏÞÇÊ
ÇáÅßËÇÑ ãä ÐßÑ Çááå æÊáÇæÉ ÇáÞÑÂä
íßÓÈäÇ ÇáÃÌÑ æÇáËæÇÈ
ÊÚÌíá ÇáÝØæÑ







ÖÚí ÚáÇãÉ ( ) Ãæ ÚáÇãÉ ( )
ÇáÊÓÇãÍ ãä ÃÎáÇÞ ÇáãÄãä ( )
ãä ÂËÇÑ ÇáÊÓÇãÍ ÇäÊÔÇÑ ÇáÚÏÇæÉ æÇáÈÛÖÇÁ ( )
ãä íÚÝ Úãä ÃÓÇÁ Åáíå íÚÝ Çááå Úäå ( )
ÇáãÓáã íäÊÞã ããä íÄÐíå ( )
ÍÏÏí ÇáÓáæß ÇáãÊÓÇãÍ æÛíÑ ÇáãÊÓÇãÍ Ýí ÇáãæÇÞÝ ÇáÊÇáíÉ :
ÃÓÇÁ Åáíå ÌÇÑå ÈÇáÞæá ÝÕãÊ æáã íÑÏ Úáíå ÈßáãÉ æÇÍÏÉ
ÇáÓáæß ÇáãÊÓÇãÍ : .................................................. ......................
ÇáÓáæß ÛíÑ ÇáãÊÓÇãÍ : .................................................. .................

ÊÓÈÈ ÑÌá Ýí ÅáÍÇÞ ÖÑÑ ÈÓíØ ÈÇáÓíÇÑÉ ÇáÊí ÃãÇãå ¡ ÝäÒá ãÚÊÐÑÇð æãÊÚåÏÇð ÈÅÕáÇÍ ÇáÓíÇÑÉ áßä ÕÇÍÈ ÇáÓíÇÑÉ ÇäåÇá Úáíå ÈÇáÞæá ÇáÓíÁ .
ÇáÓáæß ÇáãÊÓÇãÍ : .................................................. ......................
ÇáÓáæß ÛíÑ ÇáãÊÓÇãÍ : .................................................. .................

ÇÚÊÐÑÊ ÎæáÉ Åáì ÕÏíÞÊåÇ Úä ÊáÈíÉ ÏÚæÉ ÍÝ ÇáÚÔÇÁ ÇáÐí ÃÞÇãÊå ÈãäÇÓÈÉ ÝæÒåÇ ¡ ÝÛÖÈÊ ÕÏíÞÊåÇ æåÏÏÊåÇ ÈÞØÚ ÚáÇÞÊåÇ ÈåÇ ÅÐÇ áã ÊÍÖÑ
ÇáÓáæß ÇáãÊÓÇãÍ : .................................................. ......................
ÇáÓáæß ÛíÑ ÇáãÊÓÇãÍ : .................................................. .................

ÇßÊÔÝí ÇáßáãÉ ÇáäÇÞÕÉ :
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Ãåá ÇáßÊÇÈ åã :
ÇáãÔÑßæä ÇáíåæÏ æÇáäÕÇÑí ÇáãÓáãæä
Ïíä ÇáÞíãÉ åæ
ÇáíåæÏíÉ ÇáÅÓáÇãÇáäÕÑÇäíÉ
ÃÑÓá Çááå ãÍãÏ Õá Çááå Úáíå æÓáã áåÏÇíÉ
ÇáäÇÓ ÌãíÚÇ Ãåá ãßÉ ÇáíåæÏ æÇáäÕÇÑí
Ãßãáí
ÔÑ ÇáÈÑíÉ åã .................................................
ãÕíÑ ÇáßÇÝÑíä ................................................
ÌÒÇÁ ÇáãÄãäíä ........................................æ .......................................Çááå Úäåã .
ÇáãÄãä ................................................. ÇáÚÈÇÏÉ ááå æÍÏÎ
ÇÓÊÎÑÌí ãä ÇáÂíÉ ÇáßÑíãÉ :
Ñßäíä ãä ÃÑßÇä ÇáÅÓáÇã ............................ æ ....................................æÕÝ Ïíä ÇáÅÓáÇã ...............................................
ÑÊÈí ÂÏÇÈ Çáäæã :
ÚäÏãÇ ÃÓÊíÞÙ ãä Çáäæã ÃÞæá (( ÇáÍãÏááå ÇáÐí ÇÍíÇäÇ ÈÚÏ ãÇ ÃãÇÊäÇ æÅáíåÇáäÔæÑ )
ÃÐåÈ ááäæã ãÈßÑÇð
ÃäÙÝ ÃÓäÇäí ÞÈá Çáäæã
ÃÑÊÏí ãáÇÈÓ Çáäæã
ÃäÇã Úáì ÌäÈí ÇáÃíãä æÇÖÚÇ íÏí Çáíãäì Úáì ÎÏí
ÃÌãÚ ßÝí ¡ æÃÞÑà ÓæÑÉ ÇáÅÎáÇÕ æÇáãÚæÐÊíä ËáÇË ãÑÇÊ ¡ æÃäÝË ÝíåãÇ áÃãÓÍ ÈåãÇ ÌÓÏì
ÃÏÚæ ÈÏÚÇÁ Çáäæã ( ÈÇÓãß ÑÈí æÖÚÊ ÌäÈí æÈß ÃÑÝÚå ÝÃä ÃãÓßÊ äÝÓí ÝÃÑÍãåÇ æÃä ÃÑÓáÊåÇ ÝÃÍÝÙåÇ ÈãÇ ÊÍÝÙ Èå ÚÈÇÏß ÇáÕÇáÍíä

Ãßãáí ÇáÏÚÇÁ
(( ÈÇÓãß ÑÈí æÖÚÊ .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................))
ÏÚÇÁ ÇáÅÓÊíÞÇÙ ãä Çáäæã ((( ÇáÍãÏ ááå .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. ..............................................))
ÇÎÊÇÑí ÇáÅÌÇÈÉ ÇáÕÍíÍÉ :
ÇáãåÇÌÑ åæ :
ãä íÚÕí Çááå ÈÃÝÚÇáå æÃÞæÇáå .
ãä íÊÑß ÇáãÚÇÕí ÇáÊí äåì Çááå ÚäåÇ .
ãä íÔÇÑß Ãåáå æÌíÑÇäå Ýí ÃÝÑÇÍåã .
ãä íÓÇÚÏ ÇáÂÎÑíä æíÚÇæäåã .
ãä ÇáÃÚãÇá ÇáÊí ÊÓÇÚÏ Úáì ÊÑß ÇáãÚÇÕí :
ÊÐßíÑ ÇáäÝÓ ÏÇÆãÇ ÈÞæá ÇáÕÏÞ
ÇáãÍÇÝÙÉ Úáì ÇáÕáÇÉ Ýí æÞÊåÇ .
ÇáÅßËÇÑ ãä ÇáÕÏÞÉ æÇáÕæã .
ÇáãÏÇæãÉ Úáì ÐßÑ Çááå æÞÑÇÁÉ ÇáÞÑÂä .
ÖÚí ÚáÇãÉ ( ) ÃãÇã Óáæß ÇáãÓáã :
íÎÏÚ ÇáäÇÓ ÝíÈíÚåã ãäÇÒá ÛíÑ ãæÌæÏÉ áíÓÑÞ ÃãæÇáåã ( )
íÊÍÏË Úä ÇáÂÎÑíä ÝíÐßÑ ÚíæÈåã ( )
íÓÇÚÏ ãä íÍÊÇÌ ÇáãÓÇÚÏÉ ( )
íÊÍÏË Úä ÛíÑå ÈßáÇã ÍÓä ( )
íáÚä ãä íÎØì ÈÍÞå ( )
íÔÇÑß ÒãáÇÁå Ýí ãäÇÓÈÇÊåã ÇáÓÚíÏÉ ( )
ÕäÝí ÇáÃÚãÇá ÇáÂÊíÉ Åáì ÃÚãÇá ÃãÑ Çááå ÈåÇ æÃÚãÇá äåì Çááå ÚäåÇ :
ÇáßáãÉ ÇáØÈíÉ – ÈÑ ÇáæÇáÏíä – ÅíÐÇÁ ÇáÌÇÑ – ÇáÅÚÊÏÇÁ ÈÇáÖÑÈ – ÇááÚä ÒíÇÑÉ ÇáãÑíÖ – ÇáßáÇã ÇáÝÇÍÔ – ÇáÓÑÞÉ – ÇÍÊÑÇã ÇáßÈíÑ – Þæá ÇáÕÏÞ
ÃÚãÇá ÃãÑ Çááå ÈåÇ ÃÚãÇá äåì Çááå ÚäåÇ

Ãßãáí ÇáãÎØØ ÇáãÝÇåíã ÇáÂÊí :
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ÃæáÇ : Ãßãáí ÇáÂíÇÊ ÇáßÑíãÉ ãä ÓæÑÉ ÇáÈíäÉ :
Åä ÇáÐíä ßÝÑæÇ ãä ----------------------- æÇáãÔÑßíä Ýí ------------------------ ÎÇáÏíä
ÝíåÇ ¡ ÇÄáÆß åã ---------------------- ( 6) Åä ÇáÐíä ÂãäæÇ ------------------------------
ÇÄáÆß åã ------------------------ (7) ÌÒÇÄåã ÚäÏ ÑÈåã --------------------------------
ÊÌÑí ãä ÊÍÊåÇ --------------------- ÎÇáÏíä ÝíåÇ ÃÈÏÇ ----------------------------------
æÑÖæÇ Úäå Ðáß áãä ÎÔí ÑÈå (8) . ÕÏÞ Çááå ÇáÚÙíã .
ËÇäíÇ : ÖÚí ÚáÇãÉ ( ) Ãæ ( ) ÃãÇã ÇáÚÈÇÑÇÊ ÇáÊÇáíÉ :
ÃÈæ ÇáÃäÈíÇÁ åæ ÅÓÍÇÞ Úáíå ÇáÓáÇã ( )
ÅÓãÇÚíá Úáíå ÇáÓáÇã åæ ÃÈæ ÇáÚÑÈ ( )
ÓÇÚÏ ÅÓãÇÚíá Úáíå ÇáÓáÇã æÇáÏå Ýí ÈäÇÁ ÇáßÚÈÉ ( )
æáÏ ÅÈÑÇåíã Úáíå ÇáÓáÇã Ýí ÃÑÖ ÈÇÈá Ýí ÓæÑíÇ ( )
ÃÑÓá Çááå ãÍãÏ Õáì Çááå Úáíå æÓáã áåÏÇíÉ Ãåá ãßÉ ÝÞØ ( )
ÅÐÇ äæì ÇáãÓáã ÇáÎíÑ áäÝÓå æÇáãÓáãíä íÊÞÈá Çááå ãäå ( )
Ãåá ÇáßÊÇÈ åã ÇáíåæÏ æÇáäÕÇÑì ( )

ËÇáËÇ : Ãßãáí ÇáÝÑÇÛÇÊ ÇáÊÇáíÉ :
.1 ÍØã ÅÈÑÇåíã Úáíå ÇáÓáÇã ÇáÃÕäÇã ÝÛÖÈæÇ ãäå Þæãå æÃáÞæå Ýí ------------------- .
2. ---------------------- åæ Ãæá ÈíÊ æÖÚ ááäÇÓ áÚÈÇÏÉ Çááå Úáì ÇáÃÑÖ .
.3 æáÏÇ ÅÈÑÇåíã Úáíå ÇáÓáÇã åãÇ ---------------- æ ------------------ .
.4ÔÑ ÇáÈÑíÉ åã ----------------- ¡ æÎíÑ ÇáÈÑíÉ åã ----------------- .
.5ÇáßÊÈ ÇáÓãÇæíÉ åí ------------- ¡ -------------- ¡ ------------- ¡ ---------------- .
.6ÏÚÇ ÇáÅÓáÇã Åáì ÇáãÍÇÝÙÉ Úáì --------------- äÙíÝÉ æÎÇáíÉ ãä ßá ÊáæË .
.7 " ÅäãÇ ÇáÃÚãÇá ---------------- ¡ æÅäãÇ áßá ------------- --------------- "
ÕÏÞ ÑÓæá Çááå Õáì Çááå Úáíå æÓáã .
((áã íßä ÇáÐíä ßÝÑæÇ............................................. .................................................. .................................................. .................................................. .................................................. .................................................. .................................................. ............................. ÇáÈíäÉ))
ãä åæ ÑÓæá Çááå ¿.............................................
áãä ÃÑÓá ãÍãÏ Õáì Çááå Úáíå æÓáã ¿ .............................
ãÇ ÌÒÇÁ ÇáãÄãäíä ÚäÏ ÑÈåã ¿.......................................
Ãßãáí ÇáÍÏíË ÇáÔÑíÝ :-
(( Úä ÚãÑ Èä .............ÑÖí Çááå Úäå ÞÇá : ................... ÑÓæá Çááå Õáì Çááå Úáíå æÓáã íÞæá : ÅäãÇ ........................................ æÅäãÇ áßá ......................... , ............................... ))
Ãßãá ÇáÌãá ÇáÊÇáíÉ ÈÇáßáãÉ ÇáãäÇÓÈÉ ãä ÚäÏß :
1 – ãÇ ãÚäì ÇáäíÉ ¿ .................................................. ................
2 - ãä íäæí Úãá ÇáÎíÑ íäÇá .......................
3 – ÅÐÇ äæì ÇáãÓáã ÇáÎíÑ áäÝÓå æááãÓáãíä íÊÞÈá Çááå ..........................
1 - ãä åí ÎÏíÌÉ ÈäÊ ÎæíáÏ ¿
à -..................................
È-................................
Ì -...............................
2– ãÇÐÇ ÞÇáÊ ÎÏíÌÉ ááÑÓæá ÚäÏãÇ äÒá Úáíå ÇáæÍí ¿................................................. .......................
3 – ãÇÐÇ ÃãÑ Çááå ÊÚÇáì ÇáäÇÑ Ãä Êßæä Úáì ÅÈÑÇåíã Úáíå ÇáÓáÇã ¿................................................. .............................
2ÖÚ ÚáÇãÉ (P) ÃãÇã ÇáÚÈÇÑÉ ÇáÕÍíÍÉ æÚáÇãÉ ( x ) ÃãÇã ÇáÚÈÇÑÉ ÇáÎÇØÆÉ
ÃÈäÇÁ ÎÏíÌÉ : ÇáÞÇÓã ,ÚÈÏÇ ááå,ÒíäÈ,ÑÞíÉ,ÝÇØãÉ,Ãã ßáËæã ( )
æáÏ ÅÈÑÇåíã Úáíå ÇáÓáÇã Ýí ÈÇÈá Ýí ÇáÚÑÇÞ ( )
ÃÈæ ÇáÃäÈíÇÁ æÃæá ÇáãÓáãíä åæ ÅÓÍÇÞ Úáíå ÇáÓáÇã ( )
ÃÍÑÞÊ ÇáäÇÑ ÓíÏäÇ ÅÈÑÇåíã Úáíå ÇáÓáÇã ( )
ÃÊÚÇæä ááÍÝÇÙ Úáì äÙÇÝÉ ÇáÔæÇØÆ æÇáÔæÇÑÚ ãÚ ÚãÇá ÇáÈáÏíÉ ( )
( 1): ÇÎÊÑ ÇáÅÌÇÈÉ ÇáÕÍíÍÉ ããÇ Èíä ÇáÃÞæÇÓ :
ÎÏíÌÉ ÈäÊ ÎæíáÏ åí .... ÒæÌÉ ááäÈí r. { Ãæá - ËÇäí - ËÇáË }
ÊÒæÌåÇ ÇáäÈí r æßÇä ÚãÑåÇ ..... . { ËáÇËíä - ÃÑÈÚíä - ÎãÓíä }
äÒá ÇáæÍí Úáì ÑÓæá Çááår Ýí ÛÇÑ .......{ ÌÈá - ËæÑ - ÍÑÇÁ }
ÃäÌÈÊ ÇáÓíÏÉ ÎÏíÌÉ .....ÃæáÇÏ { ÎãÓÉ Ü ËãÇäíÉ Ü ÓÊÉ }
2)ÖÚ ÚáÇãÉ (P) ÃãÇã ÇáÚÈÇÑÉ ÇáÕÍíÍÉ æÚáÇãÉ ( x ) ÃãÇã ÇáÚÈÇÑÉ ÇáÎÇØÆÉ
ãä ÈäÇÊ ÇáÓíÏÉ ÎÏíÌÉ ÝÇØãÉ æÒíäÈ ( )
ÊÒæÌ ÇáäÈí ÇáÓíÏÉ ÎÏíÌÉ æÚãÑå ËáÇËíä ÚÇãÇ ( )
ÓÇÚÏÊ ÇáÓíÏÉ ÎÏíÌÉ ÇáÑÓæá ÈãÇáåÇ ( )
ßÐÈÊ ÇáÓíÏÉ ÎÏíÌÉ ÇáÑÓæá ( )
3 ): ÃÌÈ Úä ÇáÃÓÆáÉ ÇáÊÇáíÉ :
ãä åí ÎÏíÌÉ ÈäÊ ÎæíáÏ ¿................................................. .................................................. ..........
ãÇÐÇ ÞÇáÊ áÓíÏäÇ ãÍãÏ rÚäÏãÇ ÚÇÏ ÅáíåÇ ÎÇÆÝÇð ¿................................................. ................................................
ÇÎÊÇÑí ÇáÅÌÇÈÉ ÇáÕÍíÍÉ :
1 – ÇáÕÍÝ ÇáãØåÑÉ åí .........................................
ÇáíåæÏ æÇáäÕÇÑì ÇáÞÑÂä ÇáßÑíã ÇáßÊÈ ÇáÞíãÉ
2 – ÃÑÓá Çááå ãÍãÏ áåÏÇíÉ ............................
ÇáäÕÑÇäíÉ Ãåá ãßÉ ÇáäÇÓ ÌãíÚÇ
3 – æÌæÏ ÈíÆÉ äÙíÝÉ ...........................
ÈÓÇÊíä æÍÞæá ÓíÇÑÇÊ æÔÇÍäÇÊ ÖÌíÌ æÅÒÚÇÌ

Ãí ÇáÚÈÇÑÇÊ ÇáÂÊíÉ ÕÍíÍÉ ¿ æÃíåÇ ÎØà ¿
ÓÇÚÏ ÇÓãÇÚíá – Úáíå ÇáÓáÇã – æÇáÏå Ýí ÈäÇÁ ÇáßÚÈÉ . ( )
ÅÈÑÇåíã – Úáíå ÇáÓáÇã – åæ ÃÈæ ÇáÃäÈíÇÁ ( )
Âãä Ãåá ÈÇÈá ÈÏÚæÉ ÅÈÑÇåíã Úáíå ÇáÓáÇã ( )
Èäì ÇÈÑÇåíã Úáíå ÇáÓáÇã ÇáßÚÈÉ ÈÃãÑ ãä Çááå ÊÚÇáì ( )
Ãßãáí ÇáãÎØØ
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æáÏÇ ÇÈÑÇåíã Úáíå ÇáÓáÇã ...................................æ .....................................
ãä äÓá ÅÓãÇÚíá Úáíå ÇáÓáÇã ßÇä ÂÎÑ ÇáÃäÈíÇÁ .................................................. .........