S-4.2, r. 21 - Regulation respecting the designation procedure for certain members of the board of directors of a public institution

Schedule Disposition versions

2012-09-01

SCHEDULE IV

(s. 16)

DESIGNATION

Nomination Paper

Institution			I.D. No.
			
			
			
Designation college: 				
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	Province	Postal code		Nominator’s signature
				
			
Area code	
Home phone	Area code	
Work phone	
Ext.	2- Nominator’s last and first name*	
			
Occupation		Address	
Employer		Phone	
* Nominator must be a member of the above designation college.		Nominator’s signature	
Section III - Candidate’s consent			
CONDITIONS REQUIRED TO BE A MEMBER
OF AN INSTITUTION’S BOARD OF DIRECTORS			
1.	Québec resident;			
2.	Age of majority (18 or over);			
3.	Not be under wardship or guardianship;			
4.	Not found guilty in the past five years of a crime punishable by three or more years of incarceration;			
5.	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;			
6.	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.			
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 the health and social service agency and Ministère de la Santé et des Services sociaux if I am designated a member of the board of directors. Information disclosed to the agency and 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 designation officer			
Nomination accepted		Nomination rejected	
Reason(s) for rejection: 				
				
						
				
	
Designation officer’s signature				
Date	
Pursuant to sections 64 and 65 or 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 designated, 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 the 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 abovementioned act.	4. All information on the form is required.

M.O. 2006-015, Sch. IV.