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.

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

    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

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

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