APPLICATION FOR EXEMPTION
Considering that Doctor ______________________________ works exclusively for __________(name of agency)__________, it was moved by ______________________________ seconded by______________________________ and resolved (resolution no. __________) at a meeting held on ______________________________ 20__________, that it be declared, for the purposes of the Regulation respecting compulsory contribution to the professional liability insurance fund of the Ordre des dentistes du Québec (chapter D-3, r. 13):
“That ______________________________ stands surety for, defends and accepts financial responsibility for the consequences of any fault or negligence committed by Doctor ______________________________ in the performance of his duties.”.
Signed on this ______________________________ day of ______________________________ 20__________.
(authorized person, title)