VIEWS: 13 PAGES: 2 POSTED ON: 10/18/2012
Request ISSUANCE OF A CERTIFICATE OF STANDING AND AUTHORIZATION TO DISCLOSE Following the resolution adopted by the Administrative Committee of the Barreau du Québec concerning membership certificates, you will find enclosed a request that will have to be completed before such a certificate may be issued and to authorize the disclosure of any information relative to a professional, disciplinary and liability insurance history. IMPORTANT o Please print this form, complete it, sign it and send it by mail, if you pay by check. You can send it by fax or email if you pay with your credit card. o Remember to include a check, payable to the Barreau du Québec, or information regarding your credit card. No certificate will be issued without the payment of fees. I, membership number (______________), member of the Barreau du Québec, registered in the section, hereby request that the Barreau du Québec issue to me a Certificate containing any and all information regarding my standing within the Barreau du Québec, including any and all information pertaining to the practice of my profession, such as my disciplinary and professional inspection records, as the case may be. I have been the subject of criminal proceedings (indicate acts): no yes - specify: Date Nature Judgment Sentence I have been the subject of proceedings under the Bankruptcy Act: no yes - specify: a petition for a receiving order under section 43 an assignment under section 49 an application for a consolidation order under section 219 a proposal under section 50 I have been the subject of claims for professional liability: no yes - specify: Date Nature Amount Judgment If so, did you denounce the claim to the Secretary of the Order according to yes measure 62.2 of the Professional Code? no Please specify the desired language: English certificate French certificate Page 1 of 2 Last update: January 16th, 2012 Relative to the applicable rates (please check appropriate box): For one (1) certificate For two (2) certificates Amount $100.00 Amount $115.00 GST $5.00 GST $5.75 Sub-total $105.00 Sub-total $120.75 PST – 9.5% $9.97 PST – 9.5% $11.47 Total $114.98 Total $132.22 Payment By check, enclosed Cash Credit card (payable to the Barreau du Québec) (in person at la Maison du Barreau) (complete the section below) Information on the credit card VISA MASTER CARD Card number: Amount paid: $ Expiry date of the card: Month Year Signature: Date : GST: R 106773344 RT0001 PST: 1006163188 TQ0002 SIGNATURES I hereby release the Barreau du Québec, its administrators and employees from any and all responsibility which may arise from the information provided in the aforesaid Certificate. Signed at ____________________, the ______ day of the month of ________________ 20___. _________________________________________________ Signature of Applicant Solemnly declared before me at _________________, on the ____ day of the month of _____________ 20___. _________________________________________________ Advocate or other person authorized to take oaths. Please RETURN BY MAIL, BY EMAIL OR BY FAX: the original form completed and signed a check payable to the Barreau du Québec OR information regarding your credit card. Mrs. Sylvie Roy Maison du Barreau 445, Saint-Laurent Boulevard Montréal (Québec) H2Y 3T8 Phone: (514) 954-3400 ext. 3182 | Fax : (514) 954-3464 email@example.com Page 2 of 2
"ISSUANCE OF CERTIFICATE OF STANDING AND"