SCHEDULE III
Background statement under section 4 of the Regulation respecting the recruitment and
selection procedure for disciplinary council chairs of professional orders
A Indictable offence or criminal offence1
Have you been found guilty of an indictable offence or a criminal offence?
Yes No
If you have been found guilty of an indictable offence or criminal offence, please specify the offence in question and the sentence
imposed, including any offence for which you have been granted a record suspension2 within the meaning of the Criminal Records
Act (Revised Statutes of Canada 1985, chapter C-47).
B Penal offence3
Have you been found guilty of a penal offence likely to question the integrity or impartiality of the Bureau des présidents
des conseils de discipline, of yourself or of disciplinary councils, to interfere with your ability to perform your duties or to
ruin the trust of the public in you?
Yes No
If you have been found guilty of a penal offence and it is reasonable to believe that it could have the above-mentioned effects,
please specify the offence in question and the sentence imposed.
C Disciplinary decision
Have you been the subject of a complaint before a competent body of a professional order?
Yes No
If yes, describe the object of any complaint/attach any relevant document.
1 Indictable offence or criminal offence means any offence under the Criminal Code or qualified as an indictable offence or criminal
offence in any other federal law.
2 Criminal record suspension within the meaning of the Criminal Records Act (Revised Statutes of Canada 1985, chapter C-47),
formerly called pardon, is a clemency measure that may be granted to a person who has been convicted under a federal law.
Therefore, criminal record suspension is only possible in respect of an offence under the Criminal Code or another federal penal
law.
3 Penal offence means any offence, other than a criminal offence, created and penalized under a provincial or federal law or
regulation (for example the Highway Safety Act).
Have you been the subject of a disciplinary decision rendered by a competent body of a professional order or
by the Professions Tribunal?
Yes No
If yes, describe the object of any complaint/attach any relevant document.
SCHEDULE III (cont’d)
Background statement under section 4 of the Regulation respecting the recruitment and
selection procedure for disciplinary council chairs of professional orders
C Disciplinary decision (cont’d)
Have you been the subject of a complaint outside Québec that, if it had been made in Québec, would have
been made before a competent body of a professional order?
Yes No
If yes, describe the object of any complaint/attach any relevant document.
Have you been the subject of a disciplinary decision rendered outside Québec that, if it had been rendered in
Québec, would have had the effect of a decision rendered by a competent body of a professional order or by
the Professions Tribunal?
Yes No
If yes, describe the object of any complaint/attach any relevant document.
D Other situations
Are you or have you been in the last five years in a precarious financial situation?
Yes No
If yes, explain briefly.
Is there a current or past fact or situation that may have negative consequences for yourself, for the Bureau
des présidents des conseils de discipline or for disciplinary councils and that should be disclosed?
Yes No
If yes, describe the fact or situation.
I undertake to preserve the confidentiality of the filing of my candidacy and that of any decision made in respect of my candidacy.
I undertake not to exert directly or indirectly any pressure or influence on my appointment to the position of disciplinary council
chair of professional orders.
I certify that all the information provided is accurate to my knowledge.
I consent to verifications to be made concerning me with any disciplinary body, any professional order, including the Barreau du
Québec, to which I belong or have belonged, and with police authorities and credit agencies. For that purpose, my date of birth and
my social insurance number are:
_________________________________ ______________________________________________
Date of birth Social insurance number
____________________________ _______________________________________
Signature Date