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Gel fla y dol Paces?
{Provo diigociamlento del fomulai de aia, la EPS lo hizo entrga dela Carta do Derechos y Daberes
donde se presenta da manera dara su puesto ena ranking?
‘Prevod diigencianiena del ormdario de afitacén la EPS le Niza enrega dol carta de Desempafo
‘Uy el contenido del cata de derechos y deberes del afladoy dal paints?
{Ley elcorenid dela cata de dosempeti dala EPS?
‘Coma cotizanteyrepresertanta demi grupo fair,
‘hago constar mediante mi fima que compari lz
rosene cata de derechos y deberes y cata de
‘desempeio de a EPS con mis beneficlarios.
{Situ alguraduda sobre el contenido dela inlornacion fue asesorado adecuadarente porla EPS?
Firma del afitado: Gashina Tatel bya ste G
No.\dentifeaelén: Cc. ACROIALOSA
FIRMA A RUEGO (Dilgenclar exclusivamente cuando el colizante no pueda firmar)
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