‫ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺠﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﻳﻤﻘﺮﺍﻃﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ‬

‫ﻭﺯﺍﺭﺓ ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﻮﻃﻨﻴﺔ‬

‫ﺍﻟﺪﻳﻮﺍﻥ ﺍﻟﻮﻃﻨﻲ ﻟﻼﻣﺘﺤﺎﻧﺎﺕ ﻭﺍﻟﻤﺴﺎﺑﻘﺎﺕ‬
‫ﺍﺳﺘﻤﺎﺭﺓ ﻃﻠﺐ ﺍﻟﺘﺴﺠﻴﻞ ﺍﻹﻟﻜﺘﺮﻭﻧﻴﺔ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ﺩﻭﺭﺓ ‪2011:‬‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪123123:‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ ‪mouffok123:‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ ‪275-3-8202:‬‬
‫‪26-10-2010,21:2:43/1288119763/ver/1288119762‬‬ ‫ﺍﻟﻮﻻﻳــــﺔ‪:‬ﺳﻴﺪﻱ ﺑﻠﻌﺒﺎﺱ‬
‫ﺍﻟﻤؤﺳﺴــﺔ‪:‬ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ‪-‬ﺳﻴﺪﻱ ﺑﻠﻌﺒﺎﺱ‬
‫ﺍﻟﺸﻌﺒــــﺔ‪:‬ﺍﻟﻌﻠﻮﻡ ﺍﻟﺘﺠﺮﻳﺒﻴﺔ‬
‫ﺍﻟﻠﻐﺔ ﺍﻟﺜﺎﻟﺜﺔ‪/:‬‬
‫ﺍﻟﻠﻐﺔ ﺍﻷﻣﺎﺯﻳﻐﻴﺔ‪:‬ﻻ ﻟﺴﺖ ﻣﻌﻨﻲ ﺑﺎﻷﻣﺎﺯﻳﻐﻴﺔ‬
‫‪1‬‬ ‫‪2‬‬ ‫‪2‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪0‬‬ ‫‪6‬‬ ‫‪1‬‬ ‫‪2‬‬ ‫‪6‬‬
‫ﺍﻟﺘﺮﺑﻴﺔ ﺍﻟﺒﺪﻧﻴﺔ ﻭﺍﻟﺮﻳﺎﺿﻴﺔ‪:‬ﻛﻔء‬
‫ﻣﺘﺮﺷﺢ ﻓﻲ ﻗﺴﻢ‪/:‬‬

‫ﺍﻟﻠﻘﺐ ‪:‬ﻗﺪﻭﺭ ﻣﻮﻓﻖ‬

‫ﺍﻻﺳﻢ ‪:‬ﻓﺎﻃﻤﺔ ﺍﻟﺰﻫﺮﺍﺀ‬
‫ﺗﺎﺭﻳﺦ ﻭﻣﻜﺎﻥ ﺍﻟﻤﻴﻼﺩ ‪-1:‬ﺩﻳﺴﻤﺒﺮ‪1992-‬ﺑـ ‪:‬ﺳﻴﺪﻱ ﺑﻠﻌﺒﺎﺱﻭﻻﻳﺔ ‪:‬ﺳﻴﺪﻱ ﺑﻠﻌﺒﺎﺱ‬
‫‪Nom et Prénom: kaddour mouffok fatima zohra‬‬ ‫ﺍﻟﺠﻨﺲ ‪:‬ﺃﻧﺜﻰ‬
‫‪Lieu de Naissance : sidi bel abbes‬‬
‫‪Prénom du Père : houari‬‬ ‫ﺍﻟﺠﻨﺴﻴﺔ ‪:‬ﺟﺰﺍﺋﺮﻳﺔ‬
‫‪Nom et Prénom de la Mère : mokeddem atika‬‬
‫‪Tél : 665711218‬‬
‫ﻋﺪﺩ ﺍﻟﺘﺮﺷﺤﺎﺕ ﻓﻲ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ‪:‬ﻟﻠﻤﺮﺓ ﺍﻟﺜﺎﻧﻴﺔ‬
‫‪email : mimi_4.ever@hotmail.fr‬‬ ‫ﻫﻞ ﺳﺒﻖ ﻭﺃﻥ ﺣﺼﻠﺖ ﻋﻠﻰ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ؟‪:‬ﻧﻌﻢ‬
‫‪Adresse : cite des 85 logements batiment F2 bloc N°8 sorecor-daira :sidi bel abbes-wilaya :SIDI BEL ABBES‬‬

‫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.‬‬

‫ﺃﻧﺎ ﺍﻟﻤﻤﻀﻲ ﺍﺳﻔﻠﻪ ﺃﺷﻬﺪ ﺃﻥ ﻫﺬﺍ )ﻩ( ﺍﻟﻤﺘﺮﺷﺢ )ﺓ( )ﺕ( ﻳﺰﺍﻭﻝ ﺩﺭﺍﺳﺘﻪ )ﻫﺎ( ﻓﻲ ﺍﻟﺴﻨﺔ ﺍﻟﺜﺎﻟﺜﺔ ﺛﺎﻧﻮﻱ ﺑﺎﻟﻤؤﺳﺴﺔ ﻭﺃؤﻛﺪ ﺃﻥ ﺍﻟﻤﻌﻠﻮﻣﺎﺕ ﺍﻟﻤﺴﺠﻠﺔ‬
‫ﻋﻠﻰ ﻫﺬﻩ ﺍﻻﺳﺘﻤﺎﺭﺓ ﻗﺪ ﺭﺍﻗﺒﺘﻬﺎ‪.‬‬
‫ﺣﺮﺭ ﺑـ‪........................................:‬ﻔﻲ‪..................................:‬‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬ ‫ﺗﻮﻗﻴﻊ ﺍﻟﻤﺘﺮﺷﺢ‪:‬‬

‫‪26-10-2010,21:2:43/1288119763/ver/1288119762‬‬
‫ﻭﺻﻞ ﺍﺳﺘﻼﻡ ‪:‬ﻳﺸﻬﺪ ﻣﺪﻳﺮ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ ﺃﻥ ﺍﻟﺴﻴﺪ)ﺓ(‪.......................................................................‬‬
‫ﻗﺪ ﺳﻠﻢ ﻣﻠﻒ ﺍﻟﺘﺴﺠﻴﻞ ﻓﻲ ﺍﻣﺘﺤﺎﻥ ﺷﻬﺎﺩﺓ ﺍﻟﺒﻜﺎﻟﻮﺭﻳﺎ ﺩﻭﺭﺓ‪2011:‬‬
‫ﺍﻟﺮﻗﻢ ﺍﻟﺴﺮﻱ ‪123123:‬‬ ‫ﺍﺳﻢ ﺍﻟﻤﺴﺘﺨﺪﻡ ‪mouffok123:‬‬ ‫ﺭﻗﻢ ﺍﻟﻤﻠﻒ ‪275-3-8202:‬‬
‫ﺧﺘﻢ ﻭﺗﻮﻗﻴﻊ ﺭﺋﻴﺲ ﺍﻟﻤؤﺳﺴﺔ ﺃﻭ ﻣﻤﺜﻞ ﻣﺪﻳﺮﻳﺔ ﺍﻟﺘﺮﺑﻴﺔ ﺃﻭ‬ ‫ﺣﺮﺭ ﺑـ ‪................................................ :‬ﻓﻲ‪........................................:‬‬
‫ﻣﺪﻳﺮ ﺩ ﻭ ﺕ ﺕ ﻋﻦ ﺑﻌﺪ‬