Siège social
594, boulevard Queen Victoria, Sherbrooke (Québec) J1H 3R7
Téléphone : (819) 564-7100, télécopieur : (819) 564-7109
CONSENT TO DISCLOSE AND TO OBTAIN INFORMATION
Applicant’s identification:
I, the undersigned
Born on :
Address (number, street, city, postal code)
Telephone
Consent that the following establishment:
(Name and address of institution, organization or professional, or name and qualification of the person)


Disclose
Obtain
the following information or documents :

Contained in the file of :
Family and given name
Date of birth
Family and given name
Date of birth
Family and given name
Date of birth
To :(Name and address of institution, organization or professional, or name and qualification of the person)


For the following reasons:


For a period of 90 days or until the following date (maximum 1 year) :
I understand :

my rights concerning the communication of and obtaining information indicated in the document (notably my
right to obtain, consentor to refuse such a communication) ;

the reason and duration of the autorisation ;

the possibility to cancel at any time the authorisation;

that I may be required to pay certain fees, in accordance with the regulation in place (see reverse) for
requests for information on my part. Fees are not applicable for requests by an establishment in the Health
and Social Services network or governmental agency.
Signature of the applicant
In good faith I have signed :
(Place of signature)
Signature
Date
Name (in capital letters) and signature of witness
N.B
Link with the user(s)
Date
This form must be signed by :

The user himself if 14 years old and over

Authorized parental authority or legal guardian if user is under 14 years old
REGULATION FOR PAYMENT OF FEES FOR TRANSCRIPTION,
REPRODUCTION AND TRANSMISSION OF DOCUMENTS CONTAINING
NOMINATIVE1 INFORMATION
The rights provided for have been indexed to the regulation as of April 1st 2005.
1. A person, who’s right to access to a document or to an information has been recognised, is
exempt to pay the fees for transcription, reproduction and transmission of the document for up to
the sum of 6,40 $, the equivalent of 20 pages.
2. A fee of 0,37 $ per page will be required for each additional page requested.
3. A deposit equal to 50 % of the approximate cost requested by the establishment can be required
prior to the transcription, reproduction and transmission of the document, if the amount is greater
than 100$.
4. The complete payment can be required prior to the transcription, reproduction and transmission
of the document, if the costs are fixed.
5. The payment upon delivery can be requested regardless of the total amount of the fees required
to pay, either by cash, certified cheque or postal order.
Initials of signee_______
1 Loi sur l’accès aux documents des organismes publics et sur la protection des renseignements personnels