AGESSS membership form Personal information Gender Mr. Mrs Last name First Name Address City Postal code? Telephone (home) Telephone (mobile) Telephone at work E-mail (work) E-mail (personal) Date of birth Date of birth: Day Day12345678910111213141516171819202122232425262728293031 Date of birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of birth: Year Year19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 S.I.N. (Ex.: 123 456 789) Language Français Anglais I adhere to the AGESSS as : member_type Active member Retired member Professional information Establishement Position title Appointment date Function code Salary class Type of insurance Beneva Desjardins Autre Status Cadre Syndicable non syndiqué Intérim Occasionnel Other… Enter other… If you occupy an interim or occasional position, do you also hold a unionized or unionizable non-member position with that employer? Oui Non I would like to become a member of the Association des gestionnaires des établissements de santé et de services sociaux (AGESSS) and agree to comply with its current and future regulations, including the payment of membership dues. The first payment of 36.16 $ received will be considered as the entry fee. I would like to become a member of the Association des gestionnaires des établissements de santé et de services sociaux (AGESSS) and agree to comply with its current and future regulations, including the payment of membership dues. The first payment of 36.16 $ received will be considered as the entry fee. Other informations J'accepte de recevoir des informations, incluant de la publicité, par courriel ou par courrier, de l’AGESSS et de ses partenaires ? J'accepte de recevoir des informations, incluant de la publicité, par courriel ou par courrier, de l’AGESSS et de ses partenaires ? Êtes-vous membre d’un ordre professionnel ? Êtes-vous membre d’un ordre professionnel ? Ordres Professionnels Ordres Professionnels - Select -Ordre des adOrdre des administrateurs agréésministrateurs agréésOrdre des archiOrdre des architectes du Québectectes du QuébecBarreau du QuébecOrdre des comptables professionnels agréés du QuébecOrdre des conseillers en ressources humaines agréésOrdre des conseillers et conseillères d’orientation du QuébecOrdre professionnel des diététistes du QuébecOrdre des ergothérapeutes du QuébecOrdre des infirmières et infirmiers du QuébecOrdre des infirmières et infirmiers auxiliaires du QuébecOrdre des ingénieurs du QuébecOrdre professionnel des inhalothérapeutes du QuébecCollège des médecins du QuébecOrdre des pharmaciens du QuébecOrdre des psychoéducateurs et psychoéducatrices du QuébecOrdre des psychologues du QuébecOrdre professionnel des technologistes médicaux du QuébecOrdre des technologues en imagerie médicale, en radio-oncologie et en électrophysiologie médicale du QuébecOrdre des travailleurs sociaux et des thérapeutes conjugaux et familiaux du QuébecOther… Other… Payment method modedepaiements I will pay my membership dues through deduction at the source. I will submit a deduction form to my employer. (Available here) I will pay my membership dues by cheque or money order (you will receive an invoice). Signature In faith whereof, I signed this 01/04/2020 By clicking on the "Submit" button, I accept the terms and conditions of membership in the Association of Managers of Health and Social Services Institutions (AGESSS). By clicking on the "Submit" button, I accept the terms and conditions of membership in the Association of Managers of Health and Social Services Institutions (AGESSS). Other informations Type of membership New membership - I would like to become a retired member. (The annual fee is 60,00 $.) Membership renewal - I would like to renew my membership as a retired member. (The annual fee is 60,00 $.) Date of retirement Date of retirement: Day Day12345678910111213141516171819202122232425262728293031 Date of retirement: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of retirement: Year Year19301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 In the event that your residence is in a different administrative region than your former establishment, we offer you the option to change your region listed in our records. Thereby knowing if you would like to participate in the activities of the Association of the region of your former establishment or those of your home region. Région de mon domicile Région de mon ancien établissement Other… Enter other… J'accepte de recevoir des informations, incluant de la publicité, par courriel ou par courrier, de l’AGESSS et de ses partenaires? J'accepte de recevoir des informations, incluant de la publicité, par courriel ou par courrier, de l’AGESSS et de ses partenaires? Payment method mode_de_paiements_retraite Je souhaite payer ma cotisation de 60,00 $ en ligne: Assurez-vous de soumettre votre demande d’adhésion avant de cliquer sur ce lien et de payer votre cotisation en ligne I will send a check for $ 60.00 to the following address: AGESSS - 601 Adoncour Street, Suite 101 - Longueuil, Quebec - J4G 2M6 I will send the withholding authorization form to the following address: AGESSS - 601 Adoncour Street, Suite 101 - Longueuil, Quebec - J4G 2M6. My contributions will be collected by Retraite Québec (CARRA) directly on my annuities, at a r Mes cotisations seront prélevées par Retraite Québec (CARRA) directement sur mes rentes, à raison de 5,00 $ par mois (Available here) Signature In faith whereof, I signed this 01/04/2020 By clicking on the "Submit" button, I accept the terms and conditions of membership in the Association of Managers of Health and Social Services Institutions (AGESSS). By clicking on the "Submit" button, I accept the terms and conditions of membership in the Association of Managers of Health and Social Services Institutions (AGESSS). S'inscrire à la newsletter ? S'inscrire à la newsletter ?
