S-4.2, r. 22 - Regulation respecting the procedure for designating certain members of the board of directors of the public institution referred to in Part IV.2 of the Act respecting health services and social services

Schedule Disposition versions

2012-09-01

SCHEDULE V

(s. 13)

DESIGNATION

NORD-DU-QUÉBEC INSTITUTION

Candidate Information Sheet PHOTO

Institution(s): ________________________________________________________________________

Candidate’s name: ____________________________________________________________________

Municipality of Municipality of

residence: ____________________ workplace: ____________________

Candidate profile (education, occupation, experience):

Reasons for candidacy:

Social, community, volunteer involvement, etc.:

Candidate’s consent: I authorize the disclosure of the information herein as part of the designation process in which I am a candidate.

____________________ _________________________

Date Candidate’s signature

____________________ _________________________

Date Designation officer’s signature

M.O. 2006-013, Sch. V.