FICHA DE ADESÃO APUFPR X PLUS SANTÉ
TITULAR:
Nome:__________________________________________________________________________________
RG: __________________________ CPF: __________________________ Data Nasc.:
____/____/________
Endereço:_______________________________________________________________________________
Bairro:_________________________ Cidade:___________________________
CEP:___________________
Telefone:_____________________ Matrícula:__________________ Incluir o titular no plano ( ) sim ( )
não
DEPENDENTES:
Nome:__________________________________________________________________________________
RG: __________________________ CPF: __________________________ Data Nasc.:
____/____/________
Nome:__________________________________________________________________________________
RG: __________________________ CPF: __________________________ Data Nasc.:
____/____/________
Nome:__________________________________________________________________________________
Nome:__________________________________________________________________________________
RG: __________________________ CPF: __________________________ Data Nasc.:
____/____/________
Autorizo o débito das mensalidades do plano de Atendimento Pré-Hospitalar, incluso as dos dependentes, se
houver.
Data: ____/____/________ Assinatura: ______________________________________________________
Rua Gonçalves Dias nº 234 - Batel - CEP 80.240-340 - Curitiba - Paraná
Comercial 41 3342-5900
Central de Emergência 41 3342-2525