Health and social service region: RLSSSS territory: Section I - Nomination Section II - Nominators Candidate’s last and first name 1- Nominator’s last and first name Sex M F Y M D Date of birth Address
Address Phone Municipality Province Postal code Nominator’s signature *
Area Code Home phone Area Code Work phone Ext. 2- Nominator’s last and first name
Occupation Address Employer Phone * By signing below, the nominator attests that he or she is of the age of majority, does not work for any of the above institutions or at a center operated by any of said institutions, and has his or her principal residence in the health and social service region and, as the case may be, the above local service network territory. Nominator’s signature * Section III - Candidate’s consent CONDITIONS REQUIRED TO BE A MEMBER OF AN INSTITUTION’S BOARD OF DIRECTORS 1. Not be a candidate in any election other than for the institution indicated above; 2. Québec resident; 3. Age of majority (18 or over); 4. Not be under wardship or guardianship; 5. Not found guilty in the past five years of a crime punishable by three or more years of incarceration; 6. Not have been dismissed as the member of an institution’s, regional board’s, or health and social service agency’s board of directors in the past three years; 7. Not have been declared guilty in the past three years of an infraction of the Act respecting health services and social services or the regulations; 8. Not be a member of the corporate body if any of the above institutions is so designated by the minister in accordance with section 139 of the Act respecting health services and social services or considered to be so in accordance with section 601.1 of said Act; 9. Not be employed by the Ministère de la Santé et des Services sociaux, an agency, or an institution and not be employed by or receive remuneration from the Régie de l’assurance maladie du Québec; 10. Not be employed by any other body providing health or social services and receiving funding from an agency or minister; 11. Not have signed a service contract with an institution as a midwife. I hereby acknowledge that I have read this information and declare that I meet the above conditions for candidacy. I also authorize the disclosure of the information on this form to the health and social service board and the Ministère de la Santé et des Services sociaux (MSSS) if I am elected a member of the board of directors. Information disclosed to the agency and MSSS is governed by the Act respecting Access to documents held by the public bodies and the Protection of personal information. In witness whereof, I have signed in on
Section IV - Acceptance by returning officer NOMINATION ACCEPTED NOMINATION REJECTED Reason(s) for rejection:
Returning officer’s signature Date PURSUANT TO SECTIONS 64 AND 65 OF THE ACT RESPECTING ACCESS TO DOCUMENTS HELD BY PUBLIC BODIES AND THE PROTECTION OF PERSONAL INFORMATION 1. The information on this form is gathered for the institution concerned and, if the candidate is elected, for the health and social service agency and Ministère de la Santé et des Services sociaux. 2. The information transmitted to the agency and MSSS is used to make up records for management and control purposes of members of health and social service institution boards. 3. The following persons will have access to this information: Employees of the institution in question, the agency, and MSSS in the performance of their duties; Any other user meeting the requirements of the abovementioned act. 4. All information on the form is required.