‫ﺗـﺮﺧﻴـــــﺺ أﺑـــــــــــﻮي‬

‫إﻧﻲ اﻟﻤﻤﻀﻲ أﺳﻔﻞ هﺬا ‪...................................................................................................‬‬

‫ﻡﻮﻟﻮد ﻓﻲ ‪ ................................................‬ﺑـ ‪................................................................‬‬
‫ﺻﺎﺣﺐ ﺟﻮاز اﻟﺴﻔﺮٌَُ\ ﺑﻄﺎﻗﺔ اﻟﺘﻌﺮﻳﻒ اﻟﻮﻃﻨﻴﺔ ﻋﺪد ‪..................................................................‬‬
‫ﺻﺎدر)ة( ﺑـ ‪ ....................................................‬ﻓﻲ ‪........................................................‬‬
‫أرﺧﺺ ﻻﺑﻨﻲ )ﺕﻲ( ‪ .......................................‬اﻟﻤﻮﻟﻮد)ة( ﻓﻲ ‪ ........................‬ﺑـ ‪..................‬‬

‫ﻻﺳﺘﺨﺮاج ﺟﻮاز ﺳﻔﺮ‬

‫ﻟﺘﺠﺪﻳﺪ ﺟﻮاز ﺳﻔﺮﻩ‬

‫‪ .................................‬ﻓﻲ ‪..............................‬‬

‫إﻡﻀﺎء اﻟﻮﻟﻲ اﻟﺸﺮﻋﻲ‬