Fiche Transfert Externe[1]

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‫ﺍﳉﻤﻬﻮﺭﻳﺔ ﺍﳉﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﳝﻘﺮﺍﻃﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ‬ ‫‪République Algérienne Démocratique et Populaire‬‬ ‫‪Ministère de l’Enseignement Supérieur‬‬ ‫‪et de la Recherche Scientifique‬‬

‫ﻭﺯﺍﺭﺓ ﺍﻟﺘﻌﻠﻴﻢ ﺍﻟﻌﺎﱄ ﻭ ﺍﻟﺒﺤﺚ ﺍﻟﻌﻠﻤﻲ‬ ‫ﺍﳌﺮﻛﺰ ﺍﳉﺎﻣﻌﻲ ﺍﻟﺪﻛﺘﻮﺭ ﳛﲕ ﻓﺎﺭﺱ ﺑﺎﳌﺪﻳﺔ‬

‫‪CENTRE UNIVERSITAIRE‬‬ ‫‪Dr. YAHIA FARES DE MEDEA‬‬

‫ﺍﳌﺪﻳﺮﻳﺔ ﺍﳌﺴﺎﻋﺪﺓ ﻟﻠﺪﺭﺍﺳﺎﺕ ﰲ ﺍﻟﺘﺪﺭﺝ‬

‫‪Direction Adjointe des Etudes de Graduation de la‬‬

‫ﻭ ﺍﻟﺘﻜﻮﻳﻦ ﺍﳌﺘﻮﺍﺻﻞ ﻭ ﺍﻟﺸﻬﺎﺩﺍﺕ‬

‫‪Formation Continue et des Diplômes‬‬

‫ﺍﻟﺮﻗﻢ ‪) .................. :‬ﺧﺎﺹ ﺑﺎﻹﺩﺍﺭﺓ(‬

‫ﺇﺳﺘﻤﺎﺭﺓ ﻃﻠﺐ ﲢﻮﻳﻞ ﺑﲔ ﺍﳉﺎﻣﻌﺎﺕ‬ ‫ﺃﻧﺎ ﺍﻟﻄﺎﻟﺐ )ﺓ( ‪ ............................................... :‬ﺭﻗﻢ ﺗﺴﺠﻴﻠﻲ ‪.................................... :‬‬ ‫ﺍﳌﻮﻟﻮﺩ )ﺓ( ﰲ ‪ ......................................................... :‬ﻭﻻﻳﺔ ‪.................................. :‬‬ ‫ﺍﻟﻌﻨﻮﺍﻥ ﺍﻟﻜﺎﻣﻞ ‪ ................................................................. :‬ﺍﻟﺮﻣﺰ ﺍﻟﱪﻳﺪﻱ ‪................. :‬‬ ‫ﺍﳊﺎﺻﻞ ﻋﻠﻰ ﺑﻜﺎﻟﻮﺭﻳﺎ ﺷﻌﺒﺔ ‪ ............................ :‬ﺑﺘﺎﺭﻳﺦ ‪ ............... :‬ﺑﺜﺎﻧﻮﻳﺔ ‪......................... :‬‬ ‫ﺍﳌﺴﺠﻞ )ﺓ( ﲜﺎﻣﻌﺔ ‪ ........................................................ :‬ﰲ ﺳﻨﺔ ‪............................. :‬‬ ‫ﻓﺮﻉ ‪ ................................................................... :‬ﺧﻼﻝ ﺍﻟﺴﻨﺔ ﺍﳉﺎﻣﻌﻴﺔ‪200…/200… :‬‬

‫ﺃﻃﻠﺐ ﲢﻮﻳﻞ ﻣﻠﻔﻲ‬ ‫ﺇﱃ ﺟﺎﻣﻌﺔ‪ ................................................ :‬ﻣﻌﻬﺪ ‪............................................... :‬‬ ‫ﻓﺮﻉ ‪ ............................................. :‬ﺍﻟﺴﻨﺔ‪ .....................:‬ﺍﻟﺴﻨﺔ ﺍﳉﺎﻣﻌﻴﺔ ‪200…/200… :‬‬ ‫ﻟﻸﺳﺒﺎﺏ ﺍﻟﺘﺎﻟﻴﺔ ‪.................................................................................................. :‬‬ ‫ﺃﺗﻌﻬﺪ ﺑﺼﺤﺔ ﺍﳌﻌﻠﻮﻣﺎﺕ ﺍﳌﻘﺪﻣﺔ‪.‬‬ ‫ﺭﻗﻢ ﺑﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ﺍﻟﻮﻃﻨﻴﺔ‪............................. :‬‬

‫ﻗﺮﺍﺭ ﺍﳉﺎﻣﻌﺔ ﺍﳌﺴﺘﻘﺒﻠﺔ‬ ‫ﻣﻮﺍﻓﻖ‬ ‫ﻏﲑ ﻣﻮﺍﻓﻖ‬

‫ﻗﺮﺍﺭ ﺍﻹﻗﺎﻣﺔ ﺍﳉﺎﻣﻌﻴﺔ‬ ‫ﻣﻮﺍﻓﻖ‬ ‫ﻏﲑ ﻣﻮﺍﻓﻖ‬

‫ﺍﳌﺪﻳﺔ ﰲ ‪.............................. :‬‬ ‫ﺗﻮﻗﻴﻊ ﺍﻟﻄﺎﻟﺐ )ﺓ(‪:‬‬

‫ﻗﺮﺍﺭ ﺍﳉﺎﻣﻌﺔ ﺍﻷﺻﻠﻴﺔ‬ ‫ﻣﻮﺍﻓﻖ‬ ‫ﻏﲑ ﻣﻮﺍﻓﻖ‬

‫ﺍﳌﺪﻳﺔ ﰲ ‪ ......................... :‬ﺍﳌﺪﻳﺔ ﰲ ‪ ........... ......................... :‬ﰲ ‪................... :‬‬ ‫ﺍﻟﻌﻨﻮﺍﻥ‪ :‬ﺍﳌﺮﻛﺰ ﺍﳉﺎﻣﻌﻲ ﺍﻟﺪﻛﺘﻮﺭ ﳛﻲ ﻓﺎﺭﺱ ﺑﺎﳌﺪﻳﺔ – ﺣﻲ ﻋﲔ ﺍﻟﺬﻫﺐ ﺍﳌﺪﻳﺔ –‬

‫ﺍﳍﺎﺗﻒ‪/‬ﺍﻟﻔﺎﻛﺲ‪025582810 :‬‬

‫‪Adresse : Centre Universitaire Dr. Yahia Fares de Médéa –Quartier Ain D’Heb – Médéa - Tel/Fax : 025582810‬‬

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