S-4.2, r. 11 - Regulation respecting the election by the public of certain members of the board of directors of a public institution

Schedule Disposition versions

2012-09-01

SCHEDULE VI

(s. 25)

PUBLIC ELECTION

Voter Declaration

Health and social service region: ________________________________________________________

RLSSSS territory (if applicable): ________________________________________________________

Institution(s): _______________________________________________________________________

DECLARATION

I hereby declare that

— I am 18 years of age or over

— The postal code of my principal residence is __________

— My principal residence is located in the above health and social service region and local health and social service network territory, as the case may be

— I do not work for any of the above institutions or at a center operated by any of said institutions

____________________

Name

____________________

Signature

____________________

Date

SCRUTINEER: ______________________________

M.O. 2006-016, Sch. VI.