ANEXO III

INSTRUO NORMATIVA N 45 INSS/PRES, DE 6 DE AGOSTO DE 2010

FICHA DE CADASTRAMENTO
1. Identificao:
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Nome da Instituio/Grupo:
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Endereo:
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Bairro:
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Cidade: ___________________________________________________________ Estado: _________
CEP: _______________________________________ Telefone: ______________________________
nibus: ___________________________________________________________________________
rgo Mantenedor: __________________________________________________________________

2. Finalidade da instituio/grupo:
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3. Servios prestados/atividades:
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4. Usurio: ________________________________________________________________________
Faixa etria: _______________________________________________________________________
Forma de pagamento: ________________________________________________________________
Horrio de atendimento ao usurio: _____________________________________________________
rea de abrangncia:
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Documentao exigida:
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5. Outros dados complementares:
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6. Representante legal da instituio/grupo:
Nome: ____________________________________________________________________________
Cargo: ____________________________________________________________________________
7. Responsvel pelas informaes:
Nome: ____________________________________________________________________________
Cargo: ____________________________________________________________________________
Data: _____________________________