UNIVERSIDADE FEDERAL DO PAR

PR-REITORIA DE EXTENSO
DIRETORIA DE ASSISTNCIA E INTEGRAO ESTUDANTIL
PROGRAMA PERMANNCIA MODALIDADE _______________________________

REQUERIMENTO
Eu,________________________________________________________________,
discente

da

UFPA,

do

Curso

______________________________________________,

de
Campus

Graduao

de

Universitrio

de

_______________________________, matrcula_____________________, cursando o _______

semestre, portador (a) do RG ______________________ e CPF ___________________,
residente

na

Rua/Avenida

________________________________________________________________
_________________________________________________________________________,
_______,

(complemento)____________________________________________________,

Bairro _________________________, no Municpio de_______________, Estado do (e)

__________________,

telefone

celular

(91)

_____________________

___________________________________________, venho por meio deste

e-mail

solicitar

concesso do Auxlio _____________________________________, modalidade do Programa

Permanncia

da

UFPA,

pelos

seguintes

motivos:

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Nestes termos, peo deferimento.
_______________, de ______________________ de 201__.

___________________________________________
Assinatura do (a) Requerente