HOSPITAL MEMBERSHIP, ARE YOU A MEMBER?
Corporation Membership Application 2010/2011
TO:
Board of Directors
FROM:
I _________________________________ have read and understand the
membership criteria and meet the requirements. I declare that I meet the
criteria to be a voting member of the Perth and Smiths Falls District
Hospital and I agree to abide by the Mission, Vision, and Values and the
By-laws of the organization as they apply to my membership.
Signature:____________________
Date: _____________________
Home Address:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Home telephone: (
)__________________________________________
Home email:
__________________________________________
Home fax: (
)__________________________________________
Business Address:
__________________________________________
__________________________________________
__________________________________________
__________________________________________
Business telephone:(
)_________________________________________
Business email:
_________________________________________
Business fax: ( )
_________________________________________
I hereby acknowledge that I
meet the following membership qualifications which are set out in Section
2 of the Corporation=s
By-Law Number 2, namely that at the time of my application, I am:
1.
A resident of the Perth Sector of the Perth and Smiths Falls
District Hospital which includes the Town of Perth, the Township of Tay
Valley (formerly Bathurst-Burgess-Sherbrooke), Beckwith, Drummond-North
Elmsley, Lanark Highlands or a resident of the Smiths Falls
Sector of the Perth and Smiths Falls District Hospital which includes the
Town of Smiths Falls, the Townships of Elizabethtown-Kitley,
Merrickville-Wolford, Montague, Rideau Lakes for a continuous period of at
least three (3) months immediately prior thereto, and/or
2. Employed or carry on a
business in said municipality, or township for a continuous period of
three (3) months prior to this application.
3. Of the full age of
eighteen (18) years.
4. Not a member of the medical, dental or
midwifery staff of the Corporation.
5. Not an employee of the Corporation.
6. Not a spouse, dependent
child, parent, brother or sister of an employee of the Corporation.
7. Not a person who lives in
the same household as a member of the medical, dental or midwife staff or
an employee of the Corporation.
The application fee of $10.00**
must be received by April 1, 2010 and must be accompanied by the signed
application form. Please forward to:
Karen Kelly, Executive Assistant,
President and CEO
Perth and Smiths Falls District Hospital, Corporate Office
60 Cornelia St, West
Smiths Falls, ON
K7A 2H9
I fully understand that should I
knowingly falsify any portion of my application; my request for
corporation membership will be rejected.
**Please
make cheque payable to the Perth and Smiths Falls District Hospital
For Office Use Only:
Date
received:________________________
Date approved:
_______________________
Download and Print your application:
CORPORATION MEMBERSHIP APPLICATION 2010/2011
CORPORATION MEMBERSHIP APPLICATION 2010/2011
If you have any questions, please call
(613) 283-2330 x 1129.
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