For Intern Use
Faculty Coordinator
Direct Supervisor
Work Days During Vacations
Name:
Signature:
Name:
Signature:
Day:
Date:
Name:
Signature:
Name:
Signature:
Day:
Date:
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Name:
Signature:
Name:
Signature:
Day:
Date
Kingdom of Saudi Arabia ﺔﻳدﻮﻌﺴﻟا ﺔﻴﺑﺮﻌﻟا ﺔﻜﻠﻤﻤﻟا ﻲﻟﺎﻌﻟا ﻢﻴﻠﻌﺘﻟا ةرازو
Ministry of Higher Education
R
RKing Abdulaziz University ﺰﻳﺰﻌﻟا ﺪﺒﻋ ﻚﻠﻤﻟا ﺔﻌﻣﺎﺟ Faculty of Applied Medical Sciences ﺔﻴﻘﻴﺒﻄﺘﻟا ﺔﻴﺒﻄﻟا مﻮﻠﻌﻟا ﺔﻴﻠﻛ
Kingdom of Saudi Arabia א א א
א מ א א
Ministry of Higher Education
א א
King Abdulaziz University
א א מ א
Faculty of Applied Medical Sciences
א א
Clinical Affairs Agency
ﻧ ــ ﻤ ــ ﻃ جذﻮ ــ
ﻠ ــ ﺐ ﺾﻳﻮﻌﺗ ﺟإ
زﺎــ ة
ةزﺎﺟإ عﻮﺒﺳﻷا ﺔﻳﺎﻬﻧ /
ﺮﻄﻔﻟا ﺪﻴﻋ و نﺎﻀﻣر ةزﺎﺟإ /
ﻰﺤﺿﻷا ﺪﻴﻋ و ﺞﺤﻟا ةزﺎﺟإ
ﻳ ضﻮﻌ زﺎﻴﺘﻣﻻا ﺔﻨﺳ تﺎﺒﻟﺎﻃ و بﻼﻃ ﻞﻤﻋ مﻮﻳ ﻞﻛ ﻞﺑﺎﻘﻣ ةزﺎﺟإ مﻮﻴﺑ
لﻼﺧ
ﻢﺳﻻا :
Name:
ﻲﻌﻣﺎﺠﻟا ﻢﻗﺮﻟا :
Comp. No.
ا مﺎﻳﻷا دﺪﻋ ﺎﻬﻀﻳﻮﻌﺗ بﻮﻠﻄﻤﻟ
: مﻮﻳ
Number of days to be compensated: Days
ﺎﻬﻀﻳﻮﻌﺗ بﻮﻠﻄﻤﻟا مﺎﻳﻷا ﺦﻳرﺎﺗ :
ﻦﻣ / / 143 ـه
ﻰﻟإ / /
143 ـه
Date of days to be compensated:
From / /20 To / /20
ﺔﻳاﺪﺑ ﺦﻳرﺎﺗ ةزﺎﺟإ
ﺾﻳﻮﻌﺘﻟا :
ﻦﻣ / /
143 ـه
ﻰﻟإ /
/ 143 ـه
Starting Date: from / / 20
to / / 20
) 1 (
ﺐﻠﻃ
ﺾﻳﻮﻌﺗ
ةزﺎﺟﻹا
ﻒﺗﺎﻬﻟا ﻢﻗر :
Tel. No.
Mobile No. :لاﻮﺠﻟا ﻢﻗر
□ ﻖﻓاﻮﻣ
□ ﻖﻓاﻮﻣ ﺮﻴﻏ
□ Accept
□ Reject
( 2 )
ﺔﻘﻓاﻮﻣ فﺮﺸﻤﻟا
ﺮﺷﺎﺒﻤﻟا
ﻢﺳﻻا :
ﻊﻴﻗﻮﺘﻟا :
ﺦﻳرﺎﺘﻟا : Name:
Signature:
Date:
) 4 (
ﺔﻘﻓاﻮﻣ ﻞﻴآو
ﺔﻴﻠﻜﻟا
ﺔﻴﻜﻴﻨﻴﻠآﻹا نوﺆﺸﻠﻟ ﺔﻴﻠﻜﻟا ﻞﻴآو
د . ﺮهﺪﻟا ﻢﺋﺎﺻ ﻦﺴﺣ ﻦﺑ ﺪﻤﺤﻣ
Vice Dean of Clinical Affairs
Dr. Mohammed H. Saiem aldahr
A AL Ghamdi 2010
