I, the undersigned, duly authorized representative, hereby apply to become a Permittee of the Association québécoise de la production médiatique on behalf of:

CORPORATE INFORMATION

Companyname:
Address:
City: / Postal code:
Phone: / Fax:
Generale-mail address:
Is this a for-profit corporation ? / Yes / No
Producer name:
Name of authorizedrepresentative:
Title:
E-mail:

PRODUCTIONINFORMATION

GENERAL INFORMATION
Production title:
Preproductiondates : / Start : / End:
Shooting dates: / Start : / End:
single / Running time:
Type of production: / series / How manyepisodes: / Running time:
Shooting language: / French / English
Other(specify) :
Specify: / Film / Video
Digital / HD
Shooting location:
SHORT: / 10 min or less / more than 10 min
TELEVISION: / animation / vignette / captation / documentary
dramaserie / humor / game / quiz / magazine
talk show / TV movie / reality show / variety
Indicate: / Pilot? / Yes / Childrenyouth? / Yes
FEATURE FILM: / animation / documentary / fiction
OTHER(specify):
COPRODUCTION
If this is a coproduction, it is: / international / interprovincial
Country: / Canada / Quebec / Portion: / %
Portion : / %
Portion : / %
Portion : / %
BROADCASTER(S) / DISTRIBUTOR(S)
# window / Broadcaster(s) / Distributor(s) / Territories
EXEMPTION
Did the Unions allow modifications to the applicable collective agreements? / Yes No
If so, wich one (please enclose a copy):
BUDGET
BELOW THE LINE (PARTS B+C) *: / $
TOTAL PRODUCTION BUDGET*: / $ / * Canadian/Quebec portion in case of
coproduction
FEE CALCULATION
AQPM FEE (0,60% X total budget): / $
GST(R106731375) 5%: / $
PST(1006095689) 9,975%: / $
TOTAL : / $

SECOND PLATFORM–DIGITAL MEDIA COMPONENT

DIGITAL MEDIA COMPONENT SYNOPSIS
Rich and Substantial
Digital Media Component / Simple Digital Media Component
DIGITAL MEDIA PLATFORMS BROADCASTING / DISTRIBUTION
Broadcaster/Distributor / Start date / end accessibility
JJ MM YYYY JJ MM YYYY
FUNDING SOURCES

DECLARATION ANDCOMMITMENT

______in becoming a Permittee ofthe

(Companyname)

Association québécoise de la production médiatique for purposes of producing :

______

(productiontitle)

  1. Pay in advancethe applicable fee including taxes, bases on the type of production

(by certified cheque, bank draft or mail order)

2.Comply with all of the collective agreements negotiated and signed by the AQPM, for the purposes of the production hereby covered, and with the AQPM By-laws and Code of Ethics.

3.Deliver to the AQPM a complete crew list within five (5) days of the start of shooting.

4.Return any unused contracts received from the AQPM within thirty (30) days of the end of the production.

Signature / Date
Print Name
Title

Purpose of file

All information provided with regard to this application will be included in a membership file. The purpose of this file is to help the AQPM and its authorized agents to:

(i)Evaluate your membership on an ongoing basis and answer any questions you may have regarding your file;

(ii)Design and implement programs for AQPM members;

(iii)Forward information on your membership status to various unions and guilds, artist, producer, distributor and broadcaster associations, government agencies and institutions, and copyrights and neighbouring rights collectives;

(iv)Convey information on your membership status to any program or activity promoting the Quebec audiovisual film, television and Web production industry, such as the AQPM website;

The personal information contained in your file (e.g. names of delegates and Associate members) will be used only for these purposes. Except for these specific cases, access to this information will be limited to AQPM employees, representatives or authorized agents, and anyone you may authorize, as may be required to carry out their duties.

Your file will be kept at the AQPM office. You have the right to access your file and to request changes or corrections as needed. As the AQPM occasionally provides its membership list to third parties, you have the right to have personal information deleted from that list. If you wish to exercise these rights, written notification should be addressed to: Administrative Assistant, AQPM, 1470 Peel, Suite 950, Tower A, Montreal, Qc H3A 1T1, or via fax at 514-392-0232.

Consent

I, the undersigned, authorize the AQPM to disclose to third parties any personal information

contained in this membership application and any supporting documents. This consent is irrevocable for as long as it is required to achieve the purpose of the file.

I, the undersigned, consent to the AQPM, representatives and agents collect from third parties the personal information necessary to ensure the accuracy of the information contained in the form, its annexes and documents attached to this membership application.

I, the undersigned, acknowledge that AQPM has no obligation to verify the accuracy of the information contained in the form.
I, the undersigned, further agree that the AQPM disclose to third parties any personal information concerning us contained in this membership application.
These consents are irrevocable, as required for achieving the object of the file.

Name (in block letters) / Signature, Authorized / Date

representative

I wish to receive communications from the AQPM and its partners

(Articles 5.01, 5.04 and 5.05 of the AQPM By-laws)

We, the undersigned, declare to be the corporate officers of the following company:

(production companyname)

We have read the Code of Ethics amended on May 2013, by the general assembly of the AQPM before signing hereunder.

We understand that the Code of Ethics serves as a contract between the AQPM and its members and that membership in the AQPM entails a commitment on the part of the company and its corporate officers to abide by this Code of Ethics (in its present form and in any future amended version).

We agree to adhere to the AQPM Code of Ethics in accordance with the AQPM By-laws.

Officer’sname / Officer’s signature / Office
(in block letters) / (president, vice president, secretary, treasurer)

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May 2016