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‫ﺟﺪﻭﻝ ﻣﻬﺮﻫﺎﻱ ﺧﺮﻭﺝ ﻭ ﻭﺭﻭﺩ ﻣﺘﻘﺎﺿﻴﺎﻥ‬ ‫ﺧﺮﻳﺪ ﺧﺪﻣﺖ ﻭﻇﻴﻔﻪ ﻋﻤﻮﻣﻲ‬

‫ﻣﺸﺨﺼﺎﺕ ﻣﺸﻤﻮﻝ‪:‬‬ ‫ﻧﺎﻡ ﻭ ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ ‪:‬‬

‫ﻣﺘﻮﻟﺪ‪:‬‬

‫ﻧﺎﻡ ﭘﺪﺭ‪:‬‬

‫ﻧﺸﺎﻧﻲ ﻭ ﺗﻠﻔﻦ‪:‬‬ ‫ﻧﺸﺎﻧﻲ ﻭﺗﻠﻔﻦ ﺩﺭ ﺍﻳﺮﺍﻥ ‪:‬‬ ‫ﺭﺩﻳﻒ‬

‫ﺗﺎﺭﻳﺦ ﺧﺮﻭﺝ ﺍﺯ ﺍﻳﺮﺍﻥ‬

‫ﺗﺎﺭﻳﺦ ﻭﺭﻭﺩ ﺑﻪ ﺍﻳﺮﺍﻥ‬

‫ﻣﺪﺕ ﺍﻗﺎﻣﺖ ﺩﺭ ﺧﺎﺭﺝ ﺍﺯ ﻛﺸﻮﺭ‬

‫ﺷﻤﺎﺭﻩ ﺻﻔﺤﺎﺕ ﮔﺬﺭﻧﺎﻣﻪ‬

‫‪1‬‬ ‫‪2‬‬ ‫‪3‬‬ ‫‪4‬‬ ‫‪5‬‬ ‫‪6‬‬ ‫‪7‬‬ ‫‪8‬‬ ‫‪9‬‬ ‫‪10‬‬ ‫‪11‬‬ ‫‪12‬‬ ‫‪13‬‬ ‫‪14‬‬ ‫‪15‬‬ ‫ﻣﺠﻤﻮﻉ ﻣﺪﺕ ﺍﻗﺎﻣﺖ ﻣﺸﻤﻮﻝ ﺩﺭ ﺧﺎﺭﺝ ﺍﺯ ﻛﺸﻮﺭ ‪:‬‬

‫ﻧﺎﻡ ﻭ ﻧﺎﻡ ﺧﺎﻧﻮﺍﺩﮔﻲ ﻣﺄﻣﻮﺭ ﻛﻨﺴﻮﻟﻲ‬ ‫ﺗﺎﺭﻳﺦ‪ ،‬ﺍﻣﻀﺎﺀ ﻭ ﻣﻬﺮ‬


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