Formulaire du bénéficiaire / Beneficiary Form

Formulaire du bénéficiaire / Beneficiary Form

L’information fournis est confidentielle et strictement utilisée à l’étude de votre situation. Aucune information ne serai partagée en aucun cas avec des entités tierces.

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Informations générales / General information

Nom

Nom

Prénom / First name

Prénom / First name

Nom de Famille / Last name

Nom de Famille / Last name

Courriel

Email

Phone

Adresse

Adresse

Adresse

Adresse

Ville / City

Ville / City

State/Province

State/Province

Zip/Code Postal

Zip/Code Postal

Pays / Country

Pays / Country

Comment le CEMQ peut-il vous aider?

Aide alimentaire / Food aid

Aide financière / Financial aid

Aide logistique (Ex: Médicaments, meubles… / Logistic aid (Ex: prescription, furniture…)

How can the CEMQ helps you?

Décrivez votre besoin

Describe your need

Par le passé, avez-vous appliqué pour une demande d’aide au CEMQ?

Non / No

Oui / Yes

Have you applied for any type of aid from the MSCQ in the past?

Si oui, donnez plus de détails

If yes, share more details

CEMQ

Suivez-nous sur les réseaux sociaux

CONTACT

INFOLETTRE

© 2023 CEMQ All rights reserved

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