ANEXO III
Ficha de Cadastramento

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:______________________________________________________________

 

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: ________________________________________________________________________

 

7. Responsável pelas informações:
Nome: ________________________________________________________________________
Cargo: ________________________________________________________________________
Data: ______________________________