Membership Form - Corporate

To be eligible for a corporate membership, an organization must:

♦ Offer or plan to offer French language health services in Northern Ontario;

♦ Belong to one of the following categories:

• Hospitals;

• Home and Community Care;

• Community Mental Health and Addictions Agencies;

• Community Health Centres;

• Public Health Units;

• Family Health Teams;

• Long-term Care Facilities;

• Postsecondary Institutions that offer healthcare programs;

• Community Organizations;

• Other.

Every corporate member must appoint a representative who speaks French and who resides in Northern Ontario.

Membership Term

Memberships are valid as long as the member meets the current membership criteria.

Organization Name*

Organization Mailling Address*

Address, Town and Postal Code

Organization Website

Please specify which sector you represent:*

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Other (specify) :

Clientele*

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Region of the organization*

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Authorized Representative

The Authorized Representative is the person formally identified - in writing - to vote on behalf of the corporate member at the Réseau's Annual General Meeting. He or she may also vote on other issues pertaining to the Réseau business. The Authorized Representative must speak French and reside in Northern Ontario.

Name of Authorized Representative*

Title*

Professional Email Address*

Telephone and Ext*

Reseau's Activities

Would your organization like to be more actively involved with the Réseau?*

Oui/Yes

Non/No

Pas pour l'instant/Not at the moment

Board of Directors

Consultations / Focus Groups

Committees and Work Groups

Other (specify) :

Consent

I have read and understood the eligibility criteria to become a corporate member of the Réseau and certify that my organization meets these criteria.*

Electronic Signature of Executive Director*

Please type you name

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