“Declaration of applicant or holder” of information required under Section 115.8 of the Environment Quality Act (R.S.Q., c. Q-2)
Natural Person
Provide applicant’s name and, if applicable, the names of all co-owners. Additional copies of this document should be used if there is insufficient space for all names. / 1. IdentificationMr. Ms.
Year / Month / Day
Name / First name / Date of birth
Number / Street / Suite/Apartment
Municipality/City District / Postal code
Province / Country
Telephone / Extension Fax (optional)
Social Insurance Number (SIN) (optional)
Mr. Ms.
Year /
Month /
Day
Name / First name / Date of birth
No / Street / Suite/Apartment
Municipality/City District / Postal code
Province / Country
Telephone / Extension Fax (optional)
Social Insurance Number (SIN) (optional)
Mr. Ms.
Year /
Month / Day
Name / First name / Date of birth
Number / Street / Suite/Apartment
Municipality/City District / Postal code
Province / Country
Telephone / Extension Fax (optional)
Social Insurance Number (SIN) (optional)
If applicable, indicate any other names used in Québec that are on file with the Registraire des entreprises du Québec.
Other names
Only fill in if the operating name of the business does not include the owner’s full first and last names.
NEQ (Québec Business Number)
Provide full contact information of the main establishment.
Number / Street / Suite/Apartment
Municipality/City / District / Postal code
Province / Country
Telephone / Extension / Fax (optional)
Cell phone (optional) / E-mail (optional)
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A Do any of the individuals identified in Section 1 have a non-arm's length relationship[1] (within the meaning of the Taxation Act, R.S.Q, Title I-3), with an individual who exercises a similar activity, but who is subject to the suspension or revocation (or injunction or order having the same effect) of an authorization issued under the Environment Quality Act or its Regulations?
If yes, identify the individual or individuals and state the nature of the non-arm’s length relationship and type of activities exercised. / Yes No
B Are any of the individuals identified in Section 1 the prêtenom[1] of another individual?
If yes, identify that person, as well as the individual for whom they are serving as prête-nom, including contact information and date of birth. Also provide the reasons that justify the use of a prête-nom. / Yes No
C Have any of the individuals identified in Section 1 been convicted of the following offences during the last five years?
An offence that is indictable under a fiscal law and connected with activities covered by the authorization being applied for or held.
If yes, identify the individual or individuals, the nature of the offence and date of judgement, briefly describing the activities that took place when the offence was committed. / Yes No
An indictable offence connected with activities covered by the authorization being applied for or held?
If yes, identify the individual or individuals and state the nature of the criminal offence and date of judgement, briefly describing the activities that took place when the offence was committed. / Yes No
An indictable offence within the meaning of Sections 467.11 to 467.13 of the Criminal Code (R.S.C., 1985, c. C-46)?
If yes, identify the individual or individuals and state the nature of the criminal offence and date of judgement. / Yes No
D Have any of the individuals identified in Section 1 been found guilty of an offence under the Environment Quality Act or any of its Regulations during the last two years?
If yes, identify the individual or individuals and state the nature of the offence and date of judgement. / Yes No
E Have any of the individuals identified in Section 1 been found guilty during the last five years of an offence that is subject to a minimum fine of $10,000 under the Environment Quality Act or any of its Regulations (Section 115.32 of the Environment Quality Act)?
If yes, identify the individual or individuals and state the nature of the offence and date of judgement. / Yes No
F Are any of the individuals identified in Section 1 in default with respect to an order or injunction under the Environment Quality Act?
If yes, identify the individual or individuals and provide specifics and the date of the order or injunction. / Yes No
G Are any of the individuals identified in Section 1 in default with respect to payment of an amount due under the Environment Quality Act or any other law or regulation that the Minister of Sustainable Development, Environment and the Fight against Climate Change is mandated to apply, including nonpayment of a fine or an administrative monetary penalty?
If yes, identify the individual or individuals and provide the reason and amount of the debt. / Yes No
H Are any of the individuals identified in Section 1 a director, officer or shareholder of a body corporate that:
Has been found guilty of an offence under the Environment Quality Act or any of its Regulations within the last two years?
If yes, identify the individual or individuals and state the nature of the offence and date of judgement. / Yes No
Has been found guilty of an offence under the Environment Quality Act or any of its Regulations that is subject to a minimum fine of $30,000 within the last five years?
If yes, identify the individual or individuals and state the nature of the offence and date of judgement. / Yes No
Has been found guilty of an offence under a tax law that is related to the exercise of activities governed by the applied for or currently held authorization within the last five years?
If yes, identify the individual or individuals, state the nature of the offence and date of judgement and briefly describe the activities during which the tax offence was committed. / Yes No
Has been found guilty of a criminal offence that is related to the exercise of activities governed by the applied for or currently held authorization within the last five years?
If yes, identify the individual or individuals and state the nature of the criminal offence and date of judgement and briefly describe the activities during which the criminal offence was committed. / Yes No
Has been found guilty of a criminal offence within the meaning of Sections 467.11 to 467.13 of the Criminal Code (R.S.C., 1985, c. C-46) within the last five years?
If yes, identify the individual or individuals and state the nature of the criminal offence and date of judgement. / Yes No
I Have any of the individuals identified in Section 1 contracted a loan[2] to finance the activities governed by the applied for or currently held authorization? / Yes No
If yes, has the lender (or if the lender is a corporation, the corporation or any of its administrators, officers or shareholder), within the last five years:
Been found guilty of an offence under a tax law that is related to the exercise of activities governed by the applied for or currently held authorization?
If yes, identify the individual or individuals, state the nature of the offence and date of judgement and briefly describe the activities during which the offence was committed. / Yes No
Been found guilty of a criminal offence that is related to the exercise of activities governed by the applied for or currently held authorization?
If yes, state the nature of the criminal offence and date of judgement and briefly describe the activities during which the criminal offence was committed. / Yes No
Been found guilty of a criminal offence within the meaning of Sections 467.11 to 467.13 of the Criminal Code (R.S.C., 1985, c. C-46) within the last five years?
If yes, state the nature of the criminal offence and date of judgement. / Yes No
If the “Yes” box was checked for any of the four preceding questions and the lender is a natural person, provide their contact information. / Year / Month / Day
Name / First name / Date of birth
No / Street / Suite/Apartment
Municipality/City / District / Postal code
Province / Country
If the “Yes” box was checked for any of the four preceding questions and the lender is a corporation, provide its contact information.
Name
NEQ (Québec Business Number)
Number / Street / Suite/Apartment
Municipality/City / District / Postal code
Province / Country
Status Officer Administrator Shareholder
Identification Mr. Ms.
Provide the personal contact information for all administrators, officers and shareholders of the lending corporation. If space is insufficient, make copies of the form. / Year / Month / Day
Name / First name / Date of birth
Number / Street / Suite/Apartment
Municipality/City / District / Postal code
Province / Country
Current to May 15, 2014 - Declaration of applicant or holder of information required under Section 115.8 of the Environment Quality Act (R.S.Q.,c.Q2) – Natural Person
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3. Formal Declaration for a Natural person
I certify that all information provided in this declaration is accurate and complete.
Each individual identified in Section 1 must sign.Name / First name
Year / Month / Day
Signature / Date
Name / First name
Year / Month / Day
Signature / Date
Name / First name
Year / Month / Day
Signature / Date
The ministère du Développement durable, de l’Environnement et de la Lutte contre les changements climatiques may, at any time, verify and obtain information required by the application of the Environment Quality Act.
Please be advised that the ministère du Développement durable, de l’Environnement et de la Lutte contre les changements climatiques may refuse to issue or renew an authorization certificate, or may amend, suspend or revoke such a certificate if the applicant or holder has filed a false declaration or document, or false information, or has distorted a material fact to have the certificate issued, maintained or renewed (Section 115.5 (3) of the Environment Quality Act). Additionally, false or misleading declarations may lead to penal procedures.
Current to May 15, 2014 - Declaration of applicant or holder of information required under Section 115.8 of the Environment Quality Act (R.S.Q.,c.Q2) – Natural Person
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[1]Must include information required under Section 115.8 of the Environment Quality Act (L.R.Q., c. Q-2).
[1]
[2] Must include information required under Section 115.8 of the Environment Quality Act (L.R.Q., c. Q-2).