Re-enrollment application

Step 1 of 3
To become a regular member, you have to fulfil the membership application below or download the printable version and send it back to the Réseau by mail or fax.
Method of payment: Credit card and Interac Transfer.
What is the main reason why you chose the Réseau as your Professional Association?*
Correspondence language:*
- English
- French
Gender*
- Mrs.
- Mr.
Name*
First Last
Date of birth*
Example of a properly written address: 23-2285, rue Saint-Pierre, Drummondville, Quebec J2C 5A7
Address*
Civic number, Street, Apartment number City Province Postal code
Area*
Address confirmation*
- I confirm that the address above is complete and includes my apartment or rental space number if applicable.
Phone number*
Cell Phone
Email (required)*
Proof of identity*
Accepted file types: jpeg, jpg, pdf, png, gif, docx, doc, Max. file size: 25 MB.
Driver’s license, health insurance card, and/or passport)
If you have followed other trainings since your last year of contribution you can add them.
Accepted file types: jpeg, jpg, pdf, png, gif, docx, doc, Max. file size: 1 GB.

Step 3 of 3
Chart for application fees*
Subscription Amount fee as of (no taxes are applicable).
Application from the month of:*
- June (10 months - $ 175.00)
- July (9 months - $ 157.50)
- August (8 months - $ 140.00)
Payment choice*
- Credit card
- Interac e-Transfer
Credit card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card number Expiration date Security code (CVV) Cardholder name
Enter the name of the person holding the bank account that will be used to make the payment:*
Entry into force of the membership status:*
- I understand that my membership application will be processed in 1-2 business days, but my membership status will be effective only from the membership month selected above.
INTERAC PROCEDURE
To make an Interac transfer, log in to your financial institution's transactional platform and enter the information below:

1. Email: comptabilite@rmpq.ca

2. Amount:Enter the amount for the month of your membership in the chart above.

3. Secret question: * Attention * Enter the full name of the person applying for membership at the location provided for the security question.

4. Answer: rmpq2285

Please note that your request will not be processed until we receive your payment.
Month of June (10 months)
Price:
Month of July (9 months)
Price:
Month of August (8 months)
Price:
Membership Terms
Professional Covenant | Acknowledgement of the authority of the Disciplinary Committee and the Board of Directors | Limited Consent for Disclosure of Information to Third Parties*
• I certify that I am 18 years of age or older and that I am the person applying for membership to the Réseau;
• I certify that all information provided is true and complete, and I understand that any falsification of information on this application will result in cancellation of my membership and privileges as a member of the Réseau;
• I agree to keep my contact information up to date at all times;
• I agree to abide by the Réseau's Code of Ethics as well as the general regulations and to any changes thereto that may be brought from time to time;
• I acknowledge the authority of the Disciplinary Committee and the Board of Directors with regard to my conduct if I violate any terms of the Code or regulations.
• If applicable, I agree to abide by the disciplinary process and I acknowledge the authority of the Disciplinary Committee and the Board of Directors over me.
• I consent to the provision of a notice to visitors to the Réseau's website, to Réseau Members, to any insurer and any plaintiff, with respect to any penalty that may be imposed on me and the reasons for such a penalty;
• These covenants, acknowledgements and consents shall be valid so long as I am a member of the Réseau and therefore apply to any renewal of my membership.
I acknowledge that I have read the membership terms and accept them.
Name*
First Last
Date*
Allow 1-2 business days for:

Obtaining your membership number and confirmation of your status as a regular member by e-mail.

Step 1 of 3

Step 2 of 3

Step 3 of 3

Chart for application fees*

Membership Terms