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D-3, r. 13 - Regulation respecting compulsory contribution to the professional liability insurance fund of the Ordre des dentistes du Québec

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SCHEDULE 2
(s. 3)
APPLICATION FOR EXEMPTION
Considering that Doctor ______________________________ works exclusively for __________(name of agency)__________, it was moved by ______________________________ seconded by______________________________ and resolved (resolution no. __________) at a meeting held on ______________________________ 20__________, that it be declared, for the purposes of the Regulation respecting compulsory contribution to the professional liability insurance fund of the Ordre des dentistes du Québec (chapter D-3, r. 13):
“That ______________________________ stands surety for, defends and accepts financial responsibility for the consequences of any fault or negligence committed by Doctor ______________________________ in the performance of his duties.”.
Signed on this ______________________________ day of ______________________________ 20__________.
True copy
__________________________________________________
(authorized person, title)
O.C. 1750-89, Sch. 2.
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