Contact information and various information
SCHEDULE I
Contact information and various information
SURMANE GIVEN NAME Reserved for secretariat
A Contact information
Home telephone: Work telephone:
Fax at home: Fax at work:
Email: Email:
Home address: Adress at work:
Do you have permanent status as an employee of the civil service of Québec? Yes No
If yes, what is your classification?
B Personal information (Kept confidentially in the file and used, if need be, for statistical purposes
in connection with equal access employment programs)
Date of birth: Mother tongue: English French Other(s)
(specify below)
Country of birth:
Sex: Female Male Spoken language(s): English French Other(s)
(specify below)
Do you consider yourself a member of a visible
minority? Yes No
Do you consider yourself a Native person (Amerindian Written language(s): English French Other(s)
or Inuit)? Yes No (specify below)
Do you have permanent limitations that affect the In what language are you able to hear and preside over a
performance of daily life activities? hearing:
Yes (specify) No English French Other(s) (specify below)
C Years of practice as an advocate (eligibility requirement set out in section 115.3 of the Professionnal Code (chapter C-26)
Number of years of practice as advocate: Year and month of admission to the Barreau du Québec
Proof of membership with the Barreau du Québec: (attach proof to this document)
Membership card of the Barreau
Attestation from the Barreau
Not entered on the roll of the Order of Advocates (if so, give reasons)
Proof of membership with the Barreau du Québec: (attach proof to this document)
Membership card of the Barreau
Attestation from the Barreau
Not entered on the roll of the Order of Advocates (If so, give reasons)
Membership with other professionnal orders Yes
(If applicable, indicate orders)
(if yes, attach proof of membership) No
D Academic training (please begin with the last diploma obtained; attach attestations of studies)
Year Institution Diploma obtained/field