FOR CLSCs LAC-ST-LOUIS AND PIERREFONDS PROFESSIONALS ONLY

FINANCIAL REQUEST

Date
Identification of the person initiating the request
Name of health professional
Phone   Ext
Email
Name of program and directorate
Request details
Basic request
Reason for the request
Have you ever requested help from the foundation for this client? Yes      No
If yes, please justify this new request
Amount requested
Since the Foundation is a last resort for funding, what other sources have been approached?
Results of the financial research
Reason of the refusal
Program Manager Name

Signature
 

 
PLEASE NOTE: All requests must be forwarded to the Board of Directors
Email: requests@clscfondationlsl-pfds.org
Mail: CLSC du Lac-Saint-Louis, 180, avenue Cartier, Pointe-Claire, Qu├ębec H9S 4S1
Invoices must be emailed or mailed to the same addresses.