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S-5, r. 2 - Regulation respecting the issuance and renewal of permits for institutions
Schedule
Disposition versions
SCHEDULE I
(s. 1)
Gouvernement du Québec
Ministère de la Santé et des Services sociaux
APPLICATION FOR PERMIT TO OPERATE AN INSTITUTION
Minister of Health and Social Services
1075, chemin Sainte-Foy
Québec, QC
G1S 2M1
Under the Act respecting health services and social services for Cree Native persons (chapter S-5) and the Regulation respecting the issuance and renewal of permits for institutions (chapter S-5, r. 2).
__________________________________________________________________________________
Name and address of applicant
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Position of applicant
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name and address of institution
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
| | |
| Postal Code | Area Code - Telephone | Public Private
|_______|_______|________|_____________|________| □ □
Date of beginning of operation of the institution:_______________________________
__________________________________________________________________________________
AS—202C (rev. 03-1982)
_________________________________________________________________________________
|
Class and type of establishment ____________________|
| |
□ Local community service centre | Number of beds |
|____________________|
| |
|Existing Requested|
|____________________|
□ Hospital centre □ for short-term care | -- -- |
|____________________|
□ for prolonged care
____________________
□ Social service centre | |
| Number of |
□ Reception centre | beneficiaries |
_________________________________________________________|____________________|
| |
□ rehabilitation | |
___________________|____________________|
| |
□ home-care centre | |
___________________|____________________|
________________________________________________________________________________
Certificate
________________________________________________________________________________
The undersigned certifies that all conditions for the issue of a permit, as
enumerated in sections 3 and 5 of the Regulation respecting the issuance and renewal
of permits for institutions, are satisfied.
Signed at ________________________________
on this ______________________________ day
of _______________________________ 20 ____
__________________________________________________________________________________
Name and address of applicant
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Position of applicant
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Name and address of institution
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
| | |
| Postal Code | Area Code - Telephone | Public Private
|_______|_______|________|_____________|________| □ □
Date of beginning of operation of the institution:_______________________________
__________________________________________________________________________________
AS—202C (rev. 03-1982)
_________________________________________________________________________________
|
Class and type of establishment ____________________|
| |
□ Local community service centre | Number of beds |
|____________________|
| |
|Existing Requested|
|____________________|
□ Hospital centre □ for short-term care | -- -- |
|____________________|
□ for prolonged care
____________________
□ Social service centre | |
| Number of |
□ Reception centre | beneficiaries |
_________________________________________________________|____________________|
| |
□ rehabilitation | |
___________________|____________________|
| |
□ home-care centre | |
___________________|____________________|
________________________________________________________________________________
Certificate
________________________________________________________________________________
The undersigned certifies that all conditions for the issue of a permit, as
enumerated in sections 3 and 5 of the Regulation respecting the issuance and renewal
of permits for institutions, are satisfied.
Signed at ________________________________
on this ______________________________ day
of _______________________________ 20 ____
__________________________________________________________________________________
_______________________________________
(Signature of the applicant)
Important
Enclose resolution authorizing signatory to apply for a permit in the name of a legal person or, in the case of a partnership or a person operating an enterprise under a name which does not include the person’s surname and given name, a certified copy of the declaration required under the Act respecting the legal publicity of enterprises (chapter P-44.1) dated less than a month before the date of application.
