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THE QUEBEC RESPIRATORY HEALTH TRAINING PROGRAM (QR HTP) SPONSORED BY THE INSTITUTE OF CIRCULATORY AND RESPIRATORY HEALTH OF CHR AND THE HEALTH RESPIRATORY NETWORK OF THE FRS APPLICATION FORM Candidate

Name of Organization (if other than organization sponsoring event) E-mail Address I hereby certify under penalty of perjury that: SURNAME FIRST NAME SECOND GIVEN NAME COUNTY Province ZONAL CODE (if applicable): (if other than province) DATES OF OCCUPANCY OF LAND (MAYBE ONLY ONE MONTH DURING WHICH TIME OCCUPANCY COULD HAPPEN): DATE OF BIRTH (MAYBE ONLY ONE MONTH DURING WHICH TIME OCCUPANCY COULD HAPPEN): COUNTRY PROVINCE COUNTRY Province Date of Birth / / DATE OF EMAIL ADDRESS (MAYBE ONLY ONE MONTH DURING WHICH TIME OCCUPANCY COULD HAPPEN): IMPORTANT: We will be submitting this form to the Secretary of State notifying them of the vacancy. Please do not submit this form to Elections Quebec. If you do submit this form, we will be able to show that a person who received a sponsorship of 20 at the RPT in the current election was not an eligible voter at the time of voting. If your organization submitted an application within six months of the end of the sponsorship period (see below), you will not have to submit the application online. If your organization submitted more than six months after the end of the sponsorship period, submit the application online and send a copy of the sponsorship receipt to the Secretary of State. If your organization submitted more than six months after the end of the sponsorship period after the sponsorship period expired but before the next general election, you must submit the application online. We will not send an application or a notice of receipt to any organization that submitted more than six months before the general election. If you submit this application after the election date, you do so at your own risk. Once you submit or submit an application, you are considered an applicant on the date that you submit or submit. If you do not submit or submit by the required date, Elections Quebec will not consider your application.

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