‫ﺟﺎﺋﺰة‬

‫ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن‬

‫‪5‬دب ا‪5‬ﻃﻔﺎل‬

‫ﻧﻤﻮذج اﻟﺘﻘﺪم ﻟﻠﺠﺎﺋﺰة‬

 ‫ﻧﻤﻮذج اﻟﺘﺮﺷﻴﺢ ﻟﺠﺎﺋﺰة أدب ا‪%‬ﻃﻔﺎل‬

‫اﻻﺳﻢ اﻟﺮﺑﺎﻋﻲ ﻟﻠﻤﺘﻘﺪم )ﺑﺎﻟﻠﻐﺔ اﻟﻌﺮﺑﻴﺔ( وﺣﺴﺐ ﺟﻮاز اﻟﺴﻔﺮ‪:‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... ........................................................................................................................‬‬

‫اﻻﺳﻢ اﻟﺮﺑﺎﻋﻲ ﻟﻠﻤﺘﻘﺪم )ﺑﺎﻟﻠﻐﺔ ا‪A‬ﻧﺠﻠﻴﺰﻳﺔ( وﺣﺴﺐ ﺟﻮاز اﻟﺴﻔﺮ‪:‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... ........................................................................................................................‬‬

‫‪................................................................ ..........‬‬ ‫ﺗﺎرﻳﺦ اﻟﻤﻴﻼد‪ .................................................................................................. :‬ﻣﻜﺎن اﻟﻤﻴﻼد‪ .................................................................................................. :‬اﻟﺠﻨﺴﻴﺔ‪:‬‬

‫ﻋﻨﻮان ا*ﻗﺎﻣﺔ اﻟﺪاﺋﻢ‪:‬‬

‫‪.......................................................................................................................................................................................................................................................................................................................................................................................‬‬

‫‪................................................................ ............................................................... ....................................‬‬ ‫اﻟﻤﺪﻳﻨﺔ‪) ............................................................................................................................... .................................... :‬اﻟﺪوﻟﺔ(‪:‬‬

‫ﻋﻨﻮان اﻟﻤﻨﺰل‪:‬‬

‫‪................................................................ .......................‬‬ ‫ﺻﻨﺪوق اﻟﺒﺮﻳﺪ‪:‬‬ ‫‪.................................................................................................‬‬ ‫اﻟﻬﺎﺗﻒ‪ ................................................................................................. :‬اﻟﻔﺎﻛﺲ‪:‬‬

‫‪................................................................ ............................................................... .............................. ................................................................................................. ....................................................‬‬ ‫اﻟﻬﺎﺗﻒ اﻟﺨﻠﻮي ) اﻟﻨﻘﺎل(‪:‬‬

‫اﻟﻌﻤﻞ اﻟﺤﺎﻟﻲ‪:‬‬

‫‪................................................................ .............................................................. ............................... ................................................................................................ .........................................................................................................................‬‬

‫‪................................................................ .............................................................. ............................... ................................................................................................ .........................................................................................................................‬‬

‫‪................................................................ ............................................................... .............................. ................................................................................................. ........................................................................................................................‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... ........................................................................................................................‬‬

‫ﻋﻨﻮان اﻟﻌﻤﻞ‪:‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... .....................................................‬‬ ‫اﻟﺠﻬﺔ اﻟﺘﻲ ﻳﻌﻤﻞ ﻓﻴﻬﺎ‪:‬‬

‫‪................................................................ .......................‬‬ ‫ﺻﻨﺪوق اﻟﺒﺮﻳﺪ‪:‬‬ ‫‪.................................................................................................‬‬ ‫اﻟﻬﺎﺗﻒ‪ ........................................................................................ ......... :‬اﻟﻔﺎﻛﺲ‪:‬‬

‫‪............................................................................................................................... ............................................................................................................................... ........................................................................‬‬ ‫اﻟﺒﺮﻳﺪ ا‪A‬ﻟﻜﺘﺮوﻧﻲ‬

‫‪............................................................................................................................... ............................................................................................................................... ...............................................................‬‬ ‫اﻟﻤﻮﻗﻊ ا‪A‬ﻟﻜﺘﺮوﻧﻲ ‪:‬‬

‫‪................................................................ ............................................................... ....................................‬‬ ‫اﻟﻤﺪﻳﻨﺔ‪) ............................................................................................................................... .................................... :‬اﻟﺪوﻟﺔ(‪:‬‬

 ‫ﻋﻨﻮان ا*ﻧﺘﺮﻧﺖ‪:‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... ...................................................‬‬ ‫اﻟﺒﺮﻳﺪ ا‪A‬ﻟﻜﺘﺮوﻧﻲ اﻟﺨﺎص‪:‬‬

‫‪................................................................ ............................................................... ............................................................................................................................... ..............................................‬‬ ‫اﻟﻤﺪوﻧﺔ أو اﻟﻤﻮﻗﻊ اﻟﺨﺎص‪:‬‬

‫ﻋﻨﺎوﻳﻦ ا*ﻋﻼم اﻟﻤﺠﺘﻤﻌﻲ‪:‬‬

‫‪LinkedIn: ............................................................................................................................... ............................................................................................................................... ...........................................................................................‬‬

‫‪Facebook: ............................................................................................................................... ............................................................................................................................... ........................................................................................‬‬

‫‪Twitter: ............................................................................................................................... ............................................................................................................................... ................................................................................................‬‬

‫ﻣﻠﺨﺺ ﻋﻦ اﻟﻨﺘﺎج اﻟﻤﻘﺪم ﻟﻠﺠﺎﺋﺰة‪:‬‬

‫ﺗﻌﻬﺪ‪:‬‬
‫أﺗﻌﻬﺪ أﻧﺎ اﻟﻤﻮﻗﻊ أدﻧﺎه أن اﻟﻤﻌﻠﻮﻣﺎت اﻟﻤﺬﻛﻮرة أﻋﻼه و اﻟﻤﺮﻓﻘﺔ ﺑﻄﻠﺐ اﻟﺘﻘﺪم ﺣﻘﻴﻘﻴﺔ و ﺗﻌﻜﺲ إﻧﺠﺎزاﺗﻲ وﻏﻴﺮ ﻣﻨﻘﻮﻟﺔ ﻋﻦ‬
‫ﻣﺼﺎدر أﺧﺮى‪.‬‬

‫‪................................................................ ............................................................... ......................‬‬ ‫اﻟﺘﻮﻗﻴﻊ‬

 ‫آﻟﻴﺔ اﻟﺘﻘﺪم‪:‬‬
‫‪ .1‬ﻳﺘﻢ ﺗﻨﺰﻳﻞ ﻧﻤﻮذج اﻟﺘﻘﺪم ﻟﻠﺠﺎﺋﺰة ﻣﻦ ﻣﻮﻗﻊ ﻣﺆﺳﺴﺔ ﻋﺒﺪاﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن ﻋﻠﻰ ا‪A‬ﻧﺘﺮﻧﺖ ‪www.shoman.org.‬‬

‫‪ .2‬ﻳﻤ‪ p‬اﻟﻨﻤﻮذج وﻳﺮﺳﻞ ﻣﻊ ﻣﻠﺨﺺ ﻟﻠﺴﻴﺮة اﻟﺬاﺗﻴﺔ ) ‪ 4‬ﻧﺴﺦ(‪ .‬وﺻﻮرة ﻋﻦ ﺟﻮاز اﻟﺴﻔﺮ ﺑﺎ‪A‬ﺿﺎﻓﺔ إﻟﻰ )‪ (4‬ﻧﺴﺦ ورﻗﻴﺔ ﻣﻦ اﻟﻌﻤﻞ اﻟﻤﻘﺪم‬

‫ﻟﻠﺠﺎﺋﺰة إﻟﻰ ﻋﻨﻮان أﻣﺎﻧﺔ اﻟﺠﺎﺋﺰة‬

‫‪ .3‬ﺗﺮﺳﻞ ﻃﻠﺒﺎت اﻟﺘﻘﺪم ﺑﺎﻟﺒﺮﻳﺪ اﻟﻤﺴﺠﻞ ‪ /‬أو ﺑﺎﻟﺒﺮﻳﺪ ا‪A‬ﻟﻜﺘﺮوﻧﻲ إﻟﻰ اﻟﻌﻨﻮان ا‪q‬ﺗﻲ‪:‬‬

‫رﺋﻴﺲ اﻟﻬﻴﺌﺔ اﻟﻌﻠﻤﻴﺔ‬

‫ﺟﺎﺋﺰة ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن ‪L‬دب ا‪L‬ﻃﻔﺎل‬

‫ص‪.‬ب‪ (940255) :‬ﻋﻤﺎن ‪ 11194‬ا‪%‬ردن‬
‫ﻫﺎﺗﻒ‪00962-6-4645150 :‬‬
‫‪ChildLitAward@shoman.org.jo‬‬

‫ﻣﺆﺳﺴﺔ ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن‪:‬‬

‫ﺗﺄﺳﺴﺖ ﻣﺆﺳﺴﺔ ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣـﺎن ﻣﻦ ﻗﺒﻞ اﻟﺒﻨـﻚ اﻟﻌﺮﺑﻲ ﻋﺎم ‪ ،1978‬وﻫﻲ ﻣﺆﺳﺴﺔ ﻻ ﺗﻬﺪف ﻟﺘﺤﻘﻴﻖ اﻟﺮﺑﺢ ﺗﻌﻨﻰ ﺑﺎﻻﺳﺘﺜﻤـﺎر ﻓﻲ‬
‫ا‪A‬ﺑﺪاع اﻟﻤﻌﺮﻓﻲ واﻟﺜﻘﺎﻓﻲ واﻻﺟﺘﻤﺎﻋﻲ ﻟﻠﻤﺴﺎﻫﻤﺔ ﻓﻲ ﻧﻬﻮض اﻟﻤﺠﺘﻤﻌﺎت ﻓﻲ اﻟﻮﻃﻦ اﻟﻌﺮﺑﻲ ﻣﻦ ﺧﻼل اﻟﻔﻜﺮ اﻟﻘﻴﺎدي‪ ،‬ا}دب واﻟﻔﻨﻮن‪،‬‬
‫ا‪A‬ﺑﺘﻜﺎر اﻟﻤﺠﺘﻤﻌﻲ واﻟﺘﺸﻐﻴﻞ و ا‪A‬ﺑﺪاع‪.‬‬

‫‪www.shoman.org‬‬
‫‪Facebook.com/shomanfdn‬‬
‫‪Twitter.com/shomanfdn‬‬

‫إﻗﺮار‬

‫‪.............................................................................................................................. ......‬‬ ‫أﻗﺮ أﻧﺎ اﻟﻤﺘﻘﺪم‪/‬ة ‪ ..............................................................................................................................‬ﺑﺄن اﻟﻌﻤﻞ اﻟﻤﻌﻨﻮن‬

‫واﻟﺬي أﺗﻘﺪم ﺑﻪ ﻟﺠﺎﺋﺰة ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن }دب ا}ﻃﻔﺎل ﻟﺪورة اﻟﻌﺎم ‪ .......................‬ﻓﻲ ﻣﻮﺿﻮع ‪ ..................................................‬ﻫﻮ ﻣﻦ ﺗﺄﻟﻴﻔﻲ‬

‫وﻣﻌﺪ ﺧﺼﻴﺼ ًﺎ ﻟﻠﺠﺎﺋﺰة‪ ،‬وﻟﻢ ﻳﺴﺒﻖ أن ﻓﺎز ﻫﺬا اﻟﻌﻤﻞ ا}دﺑﻲ ﻓﻲ ﻣﺴﺎﺑﻘﺎت وﺟﻮاﺋﺰ وﻣﻬﺮﺟﺎﻧﺎت أﺧﺮى‪ ،‬وﻟﻢ ﻳﺴﺒﻖ ﻧﺸﺮه أو‬

‫ﻋﺮﺿﻪ‪ ،‬ﻛﻤﺎ أﺗﻌﻬﺪ ﺑﺄن ﻻ أﺷﺎرك ﺑﻪ ﻓﻲ ﺟﻮاﺋﺰ وﻣﺴﺎﺑﻘﺎت وﻣﻬﺮﺟﺎﻧﺎت أﺧﺮى أو ﻧﺸﺮه ﺣﺘﻰ ﻣﻮﻋﺪ إﻋﻼن ﻧﺘﺎﺋﺞ اﻟﺠﺎﺋﺰة‪.‬‬

‫‪............................................................................................................................... ................................................‬‬ ‫اﻻﺳﻢ‪:‬‬

‫‪............................................................................................................................... .............................................‬‬ ‫اﻟﺘﻮﻗﻴﻊ‪:‬‬

Established by the Arab Bank in 1978. The Abdul Hameed Shoman
Foundation (AHSF) is a non-profit organization dedicated to
investing in cultural and social innovation to positively impact the
communities it serves through Thought Leadership, Literature and
Arts, and Social Innovation.
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،١٩٧٨ ‫أﺳﺴﺖ ﻣﺆﺳﺴﺔ ﻋﺒﺪ اﻟﺤﻤﻴﺪ ﺷﻮﻣﺎن ﻣﻦ ﻗﺒﻞ اﻟﺒﻨﻚ اﻟﻌﺮﺑﻲ ﻋﺎم‬
‫ﺑﺪاع اﻟﻤﻌﺮﻓﻲ‬E‫ﻛﻤﺆﺳﺴﺔ ﻻ ﺗﻬﺪف ﻟﺘﺤﻘﻴﻖ اﻟﺮﺑﺢ وﺗﻌﻨﻰ ﺑﺎﻻﺳﺘﺜﻤﺎر ﻓﻲ ا‬
‫واﻟﺜﻘﺎﻓﻲ واﻻﺟﺘﻤﺎﻋﻲ ﻟﻠﻤﺴﺎﻫﻤﺔ ﻓﻲ ﻧﻬﻮض اﻟﻤﺠﺘﻤﻌﺎت ﻓﻲ اﻟﻮﻃﻦ‬
.‫ اﻻﺑﺘﻜﺎر اﻟﻤﺠﺘﻤﻌﻲ‬،‫ ا_دب واﻟﻔﻨﻮن‬،‫اﻟﻌﺮﺑﻲ ﻣﻦ ﺧﻼل اﻟﻔﻜﺮ اﻟﻘﻴﺎدي‬
‫ﺷﺮﻛﺔ ﻣﺴﺎﻫﻤﺔ ﺧﺎﺻﺔ ﻻ ﺗﻬﺪف إﻟﻰ ﺗﺤﻘﻴﻖ اﻟﺮﺑﺢ‬
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