FICHA DE ATENDIMENTO

NOME_________________________________________________________________________________________________
________________________________
PAI
_________________________________________________________________________________________________________
___________________________
MÃ E
_________________________________________________________________________________________________________
_________________________
CPF ______________________________ RG _______________________________ DATA
NASCIMENTO__________________________________________
ENDEREÇO ________________________________________________________________________________________
CEP _____________________________
TELEFONE RESIDENCIAL _____________________________________________ CELULAR
_________________________________________________
ESTADO CIVIL______________________________________PROFISSÃ O
____________________________________________________________________
E-MAIL
_________________________________________________________________________________________________________
______________________
REPRESENTANTE LEGAL
NOME_________________________________________________________________________________________________
________________________________
CPF ________________________________ RG _________________________________ DATA
NASCIMENTO______________________________________
ENDEREÇO ________________________________________________________________________________________
CEP _____________________________
ESTADO CIVIL______________________________________PROFISSÃ O
____________________________________________________________________
LOCAL DE TRABALHO
_________________________________________________________________________________________________________
_____
E-MAIL
_________________________________________________________________________________________________________
______________________
PARTE CONTRÁ RIA
NOME_________________________________________________________________________________________________
________________________________
CPF/CNPJ ________________________________ RG _________________________________ ESTADO CIVIL
_____________________________________
ENDEREÇO ________________________________________________________________________________________
CEP _____________________________
PROFISSÃ O/
ATIVIDADE___________________________________________________________________________________________
__________________
LOCAL DE TRABALHO/
ATIVIDADE___________________________________________________________________________________________
_____
RELATO DOS FATOS
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________
Declaro que as informaçõ es prestadas sã o expressã o da verdade, responsabilizando-me
civil e criminalmente pela integralidade de seu conteú do.
Pindamonhangaba/SP, _____ de _______________________ de 20____.
_______________________________________________________________________
Assinatura
Advertido (a) o (a) Declarante que todas as informaçõ es aqui prestadas devem ser
comprovadas em juízo seja através de prova documental, testemunhal ou pericial. Nã o
cabendo ao Advogado (a) buscar essas provas.

Advogada OAB/SP