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Get Canada CNESST DC100-2001 2018-2024

Sign this form and return it to your local CSST office. Signature Date Note. If we cannot make a direct deposit we will send you a cheque. No more risks of lost or stolen cheques. If you opt for direct deposit your CSST payments will be deposited directly in your bank account. You will receive notice of each transaction showing the amount deposited with explanation if necessary. Register now by completing the following form. REQUEST FOR DIRECT DEPOSIT OR MODIFICATION o Registration Effective date x DAY MONTH YEAR Modification BANK ACCOUNT Personal information print in capital letters Surname First name Health insurance No. File No. Address No. Street City Telephone No. x-x Province Apt. Www. csst. qc.ca So simple fast and efficient DC100-2001-1A 2013-01 Direct deposit affix correct postage Direct deposit Did you sign the form Did you enclose a specimen cheque marked VOID Just one number for the CSST 1 866 302-CSST 2778 laval mauricie et centre-du-qu bec 1700 boul. Laval Laval Qu bec H7S 2G6 Fax 450 668-1174 longueuil 25 boul. La Fayette Qu bec J4K 5B7 Fax 450 442-6373 saguenay lac-saint-jean saint-jean- sur-richelieu 9 rue Nicholson Salaberry-de-Valley eld Qu bec J6T 4M4 Fax 450 377-8228 Complexe du Parc 6e tage 1209 boul. du Sacr -C ur Case postale 47 Saint-F licien Qu bec G8K 2P8 Fax 418 679-5931 15 rue Gamelin Gatineau Qu bec J8X 3Y3 Fax 819 778-8699 145 boul. Saint-Joseph Saint-Jean-sur-Richelieu Qu bec J3B 6Z1 Fax 450 359-1307 Place du Fjord 901 boul. Talbot Qu bec G7H 6P8 Fax 418 545-3543 Bureau 200 1055 boul. des Forges Trois-Rivi res Qu bec G8Z 4J9 Fax 819 372-3286 outaouais valleyfield yamaska 2710 rue Bachand Saint-Hyacinthe Qu bec J2S 8B6 Fax 450 773-8126 Bureau 102 26 place Charles-De Montmagny Sorel-Tracy Qu bec J3P 7E3 Fax 450 746-1036 Simplify your life with direct deposits No more waiting in line at the bank or caisse populaire. No more risks of lost or stolen cheques. If you opt for direct deposit your CSST payments will be deposited directly in your bank account. You will receive notice of each transaction showing the amount deposited with explanation if necessary. No more risks of lost or stolen cheques. If you opt for direct deposit your CSST payments will be deposited directly in your bank account. You will receive notice of each transaction showing the amount deposited with explanation if necessary. Register now by completing the following form* REQUEST FOR DIRECT DEPOSIT OR MODIFICATION o Registration Effective date x DAY MONTH YEAR Modification BANK ACCOUNT Personal information print in capital letters Surname First name Health insurance No* File No* Address No* Street City Telephone No* x-x Province Apt. Postal code Bank account information print in capital letters Name of financial institution Account No* Note that you must have an account in a Canadian financial institution to be eligible for direct deposits. lease enclose a specimen cheque marked VOID. If you do not have a specimen cheque contact your financial institution P which can provide you with one.

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