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PROCURATION L'an deux mil Par devant nous, charg

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L'an deux mil
Par devant nous, chargé des affaires consulaires près
l'Ambassade d'Algérie à Ottawa,
a comparu(e) :
M.
Né (e) le
A
Fils (fille) de
Et de
Demeurant à
Portant CNIA ou passeport n°
Délivré par
Le
Lequel a, par la présente, constitué comme
mandataire
:
M.
Né(e) le à
Demeurant à
Auquel il donne pouvoir, pour lui et en son nom, de :
PROCURATION
TEXTE DE LA PROCURATION
Cadre réservé à l'Administration
Fait à le
Signature du mandant
ﻭﻛــــــﺎﻟﺔ
ﻓﻲ ﺳﻨﺔ ﺃﻟﻔﻴﻦ ﻭ
ﺃﻣﺎﻣﻨﺎ ﻧﺤﻦ ﺍﻟﻤﻜﻠﻒ ﺑﺎﻟﺸﺆﻭﻥ ﺍﻟﻘﻨﺼﻠﻴﺔ ﻟﺪﻯ ﺳﻔﺎﺭﺓ ﺍﻟﺠﺰﺍﺋﺮ ﺑﺄﻭﺗﺎﻭﺍ
ﻟﻘﺪ ﺣﻀﺮ/ﺕ
ﺍﻟﺴﻴﺪ/ﺓ
ﺍﻟﻤﻮﻟﻮﺩ/ﺓ ﻓﻲ
ﺑﺘﺎﺭﻳﺦ
ﺇﺑﻦ/ﺓ
ﺍﻟﺴﺎﻛﻦ/ﺓ
ﺍﻟﺤﺎﻣﻞ ﻟﺒﻄﺎﻗﺔ ﺍﻟﺘﻌﺮﻳﻒ ﺍﻟﻮﻃﻨﻲ ﺃﻭ ﺟﻮﺍﺯ ﺍﻟﺴﻔﺮ ﺭﻗﻢ
ﺍﻟﺼﺎﺩﺭ ﻋﻦ
ﺑﺘﺎﺭﻳﺦ
ﺍﻟﺬﻱ
ﻭﻛﻞ ﻭ ﺃﻧﺎﺏ ﻋﻨﻪ
ﺍﻟﺴﻴﺪ/ﺓ
ﺍﻟﻤﻮﻟﻮﺩ/ﺓ ﻓﻲ
ﺑﺘﺎﺭﻳﺦ
ﺍﻟﺴﺎﻛﻦ/ﺓ
ﻟﻴﻘﻮﻡ ﻣﻘﺎﻣﻪ ﻭ ﻳﻨﻮﺏ ﻋﻨﻪ ﻟﻠﺘﺼﺮﻑ ﺑﺈﺳﻤﻪ
ﻧﺺ ﺍﻟﻮﻛﺎﻟﺔ
le
ﺣﺮﺭ ﺏ
ﻳﻮﻡ
ﺗﻮﻗﻴﻊ ﺍﻟﻤﻮﻛﻞ/ﺓ
ﻭ
:
:
ﺍﻟﺠﻤﻬﻮﺭﻳﺔ ﺍﻟﺠﺰﺍﺋﺮﻳﺔ ﺍﻟﺪﻳﻤﻮﻗﺮﺍﻃﻴﺔ ﺍﻟﺸﻌﺒﻴﺔ
ﻭﺯﺍﺭﺓ ﺍﻟﺸﺆﻭﻥ ﺍﻟﺨﺎﺭﺟﻴﺔ
ﺳﻔﺎﺭﺓ ﺍﻟﺠﺰﺍﺋﺮ ﺑﺄﻭﺗﺎﻭﺍ
ﻛﻨﺪﺍ
MINISTERE DES AFFAIRES ETRANGERES
AMBASSADE D'ALGÉRIE À OTTAWA
CANADA
REPUBLIQUE ALGERIENNE DEMOCRATIQUE ET POPULAIRE
FORMULAIRE A REMPLIR A L'ECRAN
EN MAJUSCULES
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Completed 20 October 2021

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