ﻟا ﺔﻌﺟاﺮﻣ ةرﺎﻤﺘﺳا
ﺘ
ﻢﻴﻴﻘ
لا ﺐﺘﻜﻣ
ﻦﻴﻗﺎﻌﻤﻟﺎﺑ ﺔﺻﺎﺨﻟا ﺔﻴﺑﺮﺗ
ﺮﻜﺒﻤﻟا ﻞﺧﺪﺘﻟا تﺎﻣﺪﺧو
1
زﻮﻤﺗ
)
ﻮﻴﻟﻮﻳ
(
،
2005
ﻢﻴﻴﻘﺘﻟا ﺔﻌﺟاﺮﻣ
ﻟا ﺔﻠﺋﺎﻋ ﻢﺳا
ﺬﻴﻤﻠﺘ
لأا ﻢﺳلاا
لأا ﻢﺳا لو
ﻟا ﺔﻳﻮه ﻢﻗر لولاا ب
ﺬﻴﻤﻠﺘ
ةدلاﻮﻟا ﺦﻳرﺎﺗ
ﺔﻌﺟاﺮﻤﻟا ﺦﻳرﺎﺗ
_____________________|_______________|______________|______________|_________ |_______________
ﻟ ﻂﻴﻄﺨﺘﻟا ﻮه ﺔﻌﺟاﺮﻤﻟا ﻩﺬه فﺪه نإ
ـ
:
□
ﻲﺋاﺪﺘﺑلإا ﻢﻴﻴﻘﺘﻟا
□
ﻢﻴﻴﻘﺘﻟا ةدﺎﻋإ
□
ﺔﻴﻠهلأا ءﺎﻬﻧإ
ﻦﻴآﺮﺘﺸﻤﻟا
]
300.344
RFC §
34
[
لاا كﺮﺘﺷإ
ﺎﻤﺳا ﺔﺟرﺪﻤﻟا داﺮﻓ
ؤ
لأا ﻲﻓ ﻢه
ﻢﻴﻴﻘﺘﻟا اﺬه ﺔﻌﺟاﺮﻣ ﻲﻓ ﻞﻔﺳ
.
ﻩﺬﻬﺑ ﺎﻬﻗﺎﻓرإو ﻦﻴﻴﻓﺎﺿلإا ﻦﻴآﺮﺘﺸﻤﻟا ءﺎﻤﺳا ﻦﻳوﺪﺗ ﺐﺠﻳ
ةرﺎﻤﺘﺳلاا
.[20 USC §1414 (d)(1)(B)]
_____________________________________
ﻞﺜﻤﻣ
ﻢﻴﻠﻌﺘﻟا ﺔﻳﺮﻳﺪﻣ
وأ
ﻦﻴﻌﻤﻟا ﺺﺨﺸﻟا
_____________________________________
ﻣ
ﺔﻣﺎﻋ ﺔﻴﺑﺮﺗ سرّﺪ
_____________________________________
سرّﺪﻣ
وأ
ﻦﻴﻗﺎﻌﻤﻟﺎﺑ صﺎﺧ دوّﺰﻣ
_____________________________________
ﺮﺧﺁ ﺺﺨﺷ
__________________________________
ﺮﺧﺁ ﺺﺨﺷ
___________________________________________________________
ﻟا
ﺬﻴﻤﻠﺘ
)
اﺬه نﻮﻜﻳ ﺎﻣﺪﻨﻋ
ﺎًﻤﺋلاﻣ
(
___________________________________________________________
ﻦﻳﺪﻟاﻮﻟا ﺪﺣأ
___________________________________________________________
ﻦﻳﺪﻟاﻮﻟا ﺪﺣأ
__________________________________________________________
ﺮﺴﻔﻳ نأ ﻪﻧﺎﻜﻣﺈﺑ ﺺﺨﺷ
أ
ﻟا ﻢﻴﻴﻘﺘﻟا ﺞﺋﺎﺘﻧ دﺎﻌﺑ
ﺔﻴﻤﻴﻠﻌﺘ
ﻢﻴﻴﻘﺘﻟا ﺔﻌﺟاﺮﻣ
□
ﻰﻠﻋو ﻲﻠﺤﻤﻟا ﻲﺳرﺪﻤﻟا عﺎﻄﻘﻟاو ﻲﺳرﺪﻤﻟا ﻒﺼﻟا ﺪﻴﻌﺻ ﻰﻠﻋ ﺖﻳﺮﺟأ ﻲﺘﻟا تﺎﻤﻴﻴﻘﺘﻟا ﺎﻬﻴﻓ ﺎﻤﺑ ، ةدﻮﺟﻮﻤﻟا ﻢﻴﻴﻘﺘﻟا تﺎﻣﻮﻠﻌﻣ ﻊﻴﻤﺟ ﻊﺟار
ﻒﺼﻟا ﻞﺧاد ﻲﻓ تﺬﺧأ ﻲﺘﻟا تﺎﻈﺣلاﻤﻟاو ﺔﻳلاﻮﻟا ﺪﻴﻌﺻ
)]
c
(
1350.614
.
R
.
H
[
1
.
ﺎًﻔﺻو ﻞﻤﻋإ
:
________________________
__________________________________________________________________
___________________________________________________________________________________________________
□
ﺔﻘﻠﻌﺘﻤﻟا تﺎﻣﺪﺨﻟا يدوﺰﻣو سرﺪﻤﻟا تﺎﻈﺣلاﻣ ﻊﺟار
)]
c
(
1350.614
.
R
.
H
[
1
.
ﺎًﻔﺻو ﻞﻤﻋإ
:
_________
_________________________________________________________________________________
____