________________________________________________________________________________________________ # 街道名称 城市 州 邮编 紧急情况下需要通知的人: ________________________________________________________________________________________________________________________________________________________________________________________________ 白天电话 晚上电话 关系 地址 _________________________________________________________________________________________________________________ # 街道名称 城市 州 邮编 家庭医生:(如无,请填写“无”) _______________________________________________________________________ 姓名 电话号码 医生地址: ___________________________________________________________________________________________ # 街道名称 城市 州 邮编
☐ 业主 ☐ 租户 姓名: 地址: 城市/州/邮编: 电话: 电子邮箱: ☐ 申请人 ☐ 联系人 姓名: 地址: 城市/州/邮编: 电话: 电子邮箱: 承包商或业主 公司名称: 地址: 城市/州/邮编: 电话: 传真: *CCB 执照编号: 电工执照编号: *主管电工签名(必填):
Name........................................................................................................... Company ....................................................................................................Address....................................................................................................... City, Zip code ............................................................................................. Country....................................................................................................... Telephone................................Telefax ....................................................... E-mail ............................................................................................................................................................................
Policyholder InformaƟon (Reference your member ID card) Member ID: ___________________ Group Number: __________ First Name: ___________________ Middle IniƟal: ___________________ Last Name: ___________________ Date of Birth: ___________________ Address: _______________________________________________ City: __________ State: __________ Zip Code: __________ Phone Number: ____________________________ PaƟent InformaƟon (If different than the policyholder) First Name: ____________________________ Middle IniƟal: __________ Last Name: ____________________________ Date of Birth: __________ Address: _______________________________________________ City: __________ State: __________ Zip Code: __________ Phone Number: ____________________________与保单持有人的亲密关系:配偶子女其他受抚养人
DOI: 10.56083/RCV3N6-089 Original Receipt: 16/05/2023 Acceptance for Publication: 22/06/2023 Alex Sandro Schirmer Graduated in Computer Engineering: Avacos-Condominium Management Address: Venâncio Aires, 1352, Centro, Santa Maria-RS, Cep: 97010-002 E-mail: alex.schirmer@ecomp.ufsm.br Cesar ABASCAL Master in Computer Science Institution: Federation of Industries of the State of Santa Catarina (FIESC) Address: ADMAR GONZAGA Highway, 2765, Florianópolis-SC, Zip Code: 88034-001 E-mail: cesar.abascal@gmail.com Tarsis Natan Boff da Silva Handled Computer Engineering: Neoway Address: Rua Patrício Farias, 131, Itacorubi, Florianópolis-SC, ZIP Code: 88034-132 E-mail: tarsis.silva@ecomp.ufsm.br Daniel André Nesvera Graduated in Computer Engineering: Federal University of Santa Maria (UFSM) Address: Avenida Roraima, 1000, Camobi, Santa Maria-RS, 97105-900 E-mail daniel.nel.nevera@ecomp.ufsm.br Gabriel de Jesus Coelho da Silva Specialist in Software Architecture, Data Science and CyBerSecurity Institution: Software Ag Address: Avenida das Nações Unidas, 12901, Sao Paulo-SP, Zip Code: 04578-000 E-mail: gabriel.silva@ecomp.ufsm.brDOI: 10.56083/RCV3N6-089 Original Receipt: 16/05/2023 Acceptance for Publication: 22/06/2023 Alex Sandro Schirmer Graduated in Computer Engineering: Avacos-Condominium Management Address: Venâncio Aires, 1352, Centro, Santa Maria-RS, Cep: 97010-002 E-mail: alex.schirmer@ecomp.ufsm.br Cesar ABASCAL Master in Computer Science Institution: Federation of Industries of the State of Santa Catarina (FIESC) Address: ADMAR GONZAGA Highway, 2765, Florianópolis-SC, Zip Code: 88034-001 E-mail: cesar.abascal@gmail.com Tarsis Natan Boff da Silva Handled Computer Engineering: Neoway Address: Rua Patrício Farias, 131, Itacorubi, Florianópolis-SC, ZIP Code: 88034-132 E-mail: tarsis.silva@ecomp.ufsm.br Daniel André Nesvera Graduated in Computer Engineering: Federal University of Santa Maria (UFSM) Address: Avenida Roraima, 1000, Camobi, Santa Maria-RS, 97105-900 E-mail daniel.nel.nevera@ecomp.ufsm.br Gabriel de Jesus Coelho da Silva Specialist in Software Architecture, Data Science and CyBerSecurity Institution: Software Ag Address: Avenida das Nações Unidas, 12901, Sao Paulo-SP, Zip Code: 04578-000 E-mail: gabriel.silva@ecomp.ufsm.br
供斯内尔维尔市使用: 已验证在市区内的地址:__________ 业主姓名:______________________________________________________________________________ 邮寄地址:________________________________________ 城市:_____________________ 州:____ 邮编:__________ 联系人姓名:__________________________________ 电子邮件:____________________________ 电话:______________ 照明顾问姓名:_________________________________________________________________________ 地址 _______________________________________________城市________________________州:____ 邮编 ___________ 联系人姓名:__________________________________ 电子邮件:____________________________ 电话:______________ 电气承包商姓名(如果与照明顾问不同):______________________________________ 地址 _______________________________________________城市________________________州:____ 邮编 ___________ 联系人姓名:__________________________________ 电子邮件:____________________________ 电话:______________ GA 专业执照编号:________________________ 签发日期:_______________ 到期日期: ______________