[MODELO] Cadastro de Instituição/Grupo para Fins Sociais

ANEXO III

INSTRUÇÃO NORMATIVA Nº 77 /PRES/INSS, DE 21 DE JANEIRO DE 2015

FICHA DE CADASTRAMENTO

1. Identificação: _____________________________________________________________________________

Nome da Instituição/Grupo: __________________________________________________________________________________________________________________________________________________________

Endereço: __________________________________________________________________________________________________________________________________________________________

Bairro: _____________________________________________________________________________

Cidade: _______________________________________________________ Estado: _________

CEP: __________________________________ Telefone: ______________________________

Ônibus: _____________________________________________________________________________

Órgão Mantenedor: _____________________________________________________________________________

2. Finalidade da instituição/grupo: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. Serviços prestados/atividades: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Usuário: ____________________________________________________________________

Faixa etária: ___________________________________________________________________

Forma de pagamento: ____________________________________________________________

Horário de atendimento ao usuário: _________________________________________________

Área de abrangência: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Documentação exigida: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

5. Outros dados complementares: _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

6. Representante legal da instituição/grupo:

Nome: ________________________________________________________________________

Cargo: ________________________________________________________________________

7. Responsável pelas informações:

Nome: ________________________________________________________________________

Cargo: ________________________________________________________________________

Data: _____________________________