1. Identificação:
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Nome da Instituição/ Grupo:
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Endereço:
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Bairro:
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Cidade:________________________________________ Estado: ________________________ |
CEP:______________________________ Telefone: ___________________________________ |
Ônibus:_______________________________________________________________________ |
Órgão Mantenedor:______________________________________________________________ |
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2. Finalidade da instituição/ grupo: |
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3. Serviços prestados/ atividades:
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4. Usuário: ____________________________________________________________________ |
Faixa etária: ___________________________________________________________________ |
Forma de pagamento: ____________________________________________________________ |
Horário de Atendimento ao usuário: _________________________________________________ |
Área de abrangência:
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Documentação exigida:
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5. Outros Dados Complementares:
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6. Representante legal da instituição/ grupo:
Nome: ________________________________________________________________________
Cargo: ________________________________________________________________________ |
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7. Responsável pelas informações:
Nome: ________________________________________________________________________
Cargo: ________________________________________________________________________
Data: ______________________________ |
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