S-4.2, r. 12 - Regulation respecting the election by the public of 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 I

(s. 10)

PUBLIC ELECTION NORD-DU-QUÉBEC INSTITUTION

Nomination

Institution: 				
				
Subregion number: 		Description: 				
Section I - Nomination		Section II - Nominators	
Candidate’s last and first name		1- Nominator’s last and first name	
Sex
M 	F	Date of birth
	Y	M	D	Address	
			
Address		Phone	
Municipality/Locality	Province	Postal Code	Nominator’s signature*
				
Area code	Home phone	Area code
Work phone
Ext.	2- Nominator’s first and last name	
			
Occupation		Address	
Employer		Phone	
* By signing below, the nominator attests that he or she is of the age of majority, does not work for the above institution or at a center operator by said institution, and has his or her residence in the above subregion.		Nominator’s signature*	
Section III - Candidate’s consent			
Conditions required to be a member of an institution’s board of directors			
1.	Not be a candidate in any subregion other than the one indicated above;			
2.	Québec resident;			
3.	Age of majority (18 or over);			
4.	Not be under wardship or guardianship;			
5.	Not found guilty in the past five years of a crime punishable by three or more years of incarceration;			
6.	Not have been dismissed as the member of an institution’s, regional board’s, or health and social service agency’s board of directors in the past three years;			
7.	Not have been declared guilty in the past three years of an infraction of the Act respecting health services and social services or the regulations;			
8.	Not be employed by Ministère de la Santé et des Services sociaux, an agency, or an institution and not be employed by or receive remuneration from Régie de l’assurance maladie du Québec;			
9.	Not be employed by any other body providing health or social services and receiving funding from an agency or minister;			
10.	Not have signed a service contract with an institution as a midwife;			
11.	Not be employed by a community organization.			
I hereby acknowledge that I have read this information and declare that I meet the above conditions for candidacy. I also authorize the disclosure of the information on this form to Ministère de la Santé et des Services sociaux if I am elected a member of the board of directors. Information disclosed to MSSS is governed by the Act respecting Access to documents held by public bodies and the Protection of personal information.			
In witness whereof, I have signed in 	 on  				
				
		Candidate’s signature	
Section IV - Acceptance by returning officer			
Nomination accepted		Nomination rejected	
Reason(s) for rejection: 			
				
									
									
	
Returning officer’s signature				
Date	
Pursuant to sections 64 and 65 of the Act respecting Access to documents held by public bodies and the Protection of personal information			
1.	The information on this form is gathered for the institution concerned and, if the candidate is elected, for the health and social service agency and Ministère de la Santé et des Services sociaux.	2.		The information transmitted to the agency and MSSS is used to make up records for management and control purposes of members of health and social service institution boards.	3.	The following persons will have access to this information:
	employees of the institution in question, the agency and MSSS in the performance of their duties;
	any other user meeting the requirements of the above-mentioned act.	4.		All information on the form is required.

M.O. 2006-014, Sch. I.