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Nom Prénom
Nom de jeune fille Date de naissance {"name":"datenaissance","value":"","required":true,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
{"name":"datenaissance","value":"","required":true,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Assistant(e) familial(e)
Joindre la copie de votre contrat et/ou arrêté {"name":"document1","label":"Parcourir...document 1","size_max":"5M","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d6966bd8","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...document 1","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d6966bd8"}}
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{"name":"document3","label":"Parcourir...document 3","size_max":"5M","required":false,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d69676a4","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...document 3","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d69676a4"}}
Joindre une copie de votre dernier bulletin de salaire {"name":"salaire","label":"Parcourir...","size_max":"5M","required":true,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d6967aff","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d6967aff"}}
{"name":"salaire","label":"Parcourir...","size_max":"5M","required":true,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d6967aff","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d6967aff"}}
Joindre votre RIB {"name":"RIB","label":"Parcourir...","size_max":"5M","required":true,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d6967ee2","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d6967ee2"}}
{"name":"RIB","label":"Parcourir...","size_max":"5M","required":true,"typeMimes":{"application\/msword":["doc"],"application\/vnd.openxmlformats-officedocument.wordprocessingml.document":["docx"],"application\/vnd.ms-excel":["xla","xls","xlt","xlw"],"application\/vnd.openxmlformats-officedocument.spreadsheetml.sheet":["xlsx"],"image\/jpeg":["jpg","jpeg"],"image\/gif":["gif"],"image\/png":["png"],"application\/pdf":["pdf"],"application\/x-download":["pdf"],"application\/download":["pdf"],"application\/octet-stream":["pdf"],"application\/octetstream":["pdf"]},"multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"64839d6967ee2","transmit":true,"label_max":"","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","value":false,"html":"","initializeJS":true,"size_max_byte":5242880,"button":{"value":"Parcourir...","title":"Le poids d'un fichier \u00e0 transmettre ne peut exc\u00e9der 5M. Les formats de fichier accept\u00e9s sont doc, docx, xla, xls, xlt, xlw, xlsx, jpg, jpeg, gif, png, pdf.","class":"","id":"64839d6967ee2"}}
Adresse personnelle :
Code postal : Ville :
Numéro de téléphone : Numéro de téléphone pro :
Adresse mail personnel :
Lieu de travail : Choisir...Hôtel du départementService extérieurAutre Nom du service :
Célibataire Marié(e) Union libre Pacsé(e) Veuf/veuve Divorcé(e)
Conjoint ou concubin vivant au domicile de l’adhérent Choisir...MonsieurMadame Nom Prénom Date de naissance {"name":"naissanceconjoint","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
{"name":"naissanceconjoint","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Enfants
Nom enfant 1 : Prénom enfant 1 : Date de naissance : {"name":"naissanceenf1","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant Choisir statut enfant...Enfant de l’adhérent jusqu’à 20 ans révolusEnfant placéenfant du conjoint à charge (jusqu’à 20 ans révolus) Merci d'indiquer obligatoirement le statut de votre enfant
{"name":"naissanceenf1","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Nom enfant 2 : Prénom enfant 2 : Date de naissance : {"name":"naissanceenf2","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant Choisir statut enfant...Enfant de l’adhérent jusqu’à 20 ans révolusEnfant placéEnfant du conjoint à charge (jusqu’à 20 ans révolus) Merci d'indiquer obligatoirement le statut de votre enfant
{"name":"naissanceenf2","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Nom enfant 3 : Prénom enfant 3 : Date de naissance : {"name":"naissanceenf3","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant
{"name":"naissanceenf3","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Choisir statut enfant...Enfant de l’adhérent jusqu’à 20 ans révolusEnfant placéEnfant du conjoint à charge (jusqu’à 20 ans révolus) Merci d'indiquer obligatoirement le statut de votre enfant
Nom enfant 4 : Prénom enfant 4 : Date de naissance : {"name":"naissanceenf4","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant
{"name":"naissanceenf4","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Nom enfant 5 : Prénom enfant 5 :
Date de naissance : {"name":"naissanceenf5","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant
{"name":"naissanceenf5","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Nom enfant 6 : Prénom enfant 6 : Date de naissance : {"name":"naissanceenf6","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null} Sexe Choisir...MasculinFéminin Merci d'indiquer obligatoirement le sexe de votre enfant
{"name":"naissanceenf6","value":"","required":false,"disabled":false,"showTime":false,"rows":1,"cols":1,"title":false,"showDate":true,"preloadCalendar":false,"id":null,"placeholder_date":false,"placeholder_time":false,"size":"","start_id":"","class":"","class-time":"","calendar":{"cols":1,"rows":1,"dateCursor":"pointer"},"valueViewDate":"","valueViewTime":"","formatDate":"d\/m\/Y","formatTime":"H:i","checkDateOnLoad":false,"autocomplete":null}
Je demande mon adhésion au Comité des Oeuvres Sociales du Personnel du Département de la Seine-Maritime (APSM). Pour les agents mis à disposition : je certifie sur l’honneur ne bénéficier d’aucune action sociale, culturelle ou de loisirs de mon administration d’origine
La loi n°78-17 du 6 janvier 1978 modifiée relative à l’informatique, aux fichiers et aux libertés s’applique aux informations figurant dans ce formulaire et aux traitements qui leur sont associés. Conformément aux articles 32, 39 et 40 de cette loi, les personnes auprès desquelles sont recueillies des informations nominatives sont notamment informées que : 1. Les réponses obligatoires sont mentionnées par un astérisque(*). Un défaut de réponse entraînera des retards ou une impossibilité dans l’instruction du dossier. 2. Les destinataires des informations collectées sont les agents de l’APSM habilités à instruire les dossiers et le cas échéant les administrations et organismes conventionnés par l’APSM au vu de leur mission spécifique. 3. En tout état de cause, les personnes bénéficient d’un droit d’accès et de rectification aux informations qui les concernent. Elles peuvent exercer ce droit en envoyant un courrier électronique à l’APSM (apsm@seinemaritime.fr) ou en adressant un courrier à l’adresse suivante : APSM, Département de la Seine-Maritime, Hôtel du département, Quai Jean Moulin, 76101 Rouen Cedex 1. La gestion des adhérents de l’APSM fait l’objet de déclarations à la CNIL, enregistrées sous les références 1970307 v 0 et 1970598 v 0.
Test anti-robots
Quel est le quatrième mois de l'année ?