APPLICATION FOR EXEMPTION
I wish to be exempted from contributing to the professional liability insurance fund of the Ordre des dentistes du Québec because:
□ I work exclusively for the Gouvernement du Québec and am appointed in accordance with the Public Service Act (chapter F-3.1.1);
□ I work exclusively for an agency the majority of whose members are appointed by the Gouvernement du Québec or by one of its ministers, whose personnel is appointed by law in accordance with the Public Service Act or whose capital forms part of the domain of the State, or for an agency designated by law as a mandatary of the Government;
□ I work exclusively for the “Public Service” of Canada as defined in section 2 of the Public Service Labour Relations Act (S.C. 2003, c. 22), for the “Canadian Forces” within the meaning of section 14 of the National Defence Act (R.S.C. 1985, c. N-5), or for a “Crown corporation” within the meaning of subsection 1 of section 83 of the Financial Administration Act (R.S.C. 1985, c. F-11) and mentioned in the schedules to that Act;
□ I work exclusively for a municipality, a regional county municipality, the Communauté métropolitaine de Québec, the Communauté métropolitaine de Montréal, Ville de Gatineau, a school board or the Comité de gestion de la taxe scolaire de l’île de Montréal;
□ I am entered on the roll, but under no circumstances do I perform any of the acts specified in Division V of the Dental Act (chapter D-3);
□ I work exclusively for the faculty or school of dentistry of a Québec university;
□ I am working exclusively to complete a full-time university graduate program in a specialty recognized by the Order;
□ I am undergoing full-time training within the framework of a program recognized by the Order and I limit the practice of my profession to that training.
I undertake to notify the secretary in writing immediately of any change modifying in any way the reason for my exemption from contributing to the professional liability insurance fund of the Ordre des dentistes du Québec.
Sworn before me at ______________________________ this ______________________________ day of ______________________________ 20__________.
Commissioner for oaths