Société de l’assurance automobile du Québec
7537A 30 (2018-02)
This number can be found at the beginning
of the letter sent to you by the SAAQ.
Registration Form for the Program to Assess and Reduce the Risk
of Impaired Driving (PERRCCA)
Goal of an Assessment or a Supervision Plan
The Société de l’assurance automobile du Québec (SAAQ) requires that you undergo an assessment or comply with a supervision plan in
order to ensure that your behaviour in relation to alcohol and/or drugs is consistent with the safe operation of a road vehicle. You must comply
with this requirement in order to keep your driver’s licence or obtain a new one. An assessment professional recognized by the Centre intégré
universitaire de santé et de services sociaux (CIUSSS) du Centre-Sud-de-l’Île-de-Montréal will carry out the assessment and, if applicable,
develop the supervision plan. Note that the assessment professional will be someone in your administrative region.
Protection of Personal Information
All personal information gathered by the CIUSSS du Centre-Sud-de-l’Île-de-Montréal and authorized Société de l’assurance automobile
du Québec (SAAQ) personnel is handled condentially. The SAAQ requires this information to apply the Automobile Insurance Act, the
Act respecting the Société de l’assurance automobile du Québec and the Highway Safety Code. Under the Act respecting Access to
documents held by public bodies and the Protection of personal information, this information may be conveyed to the SAAQ’s licensing
agents and other Government departments or agencies, or used for statistical, survey, study, audit or investigative purposes. Failure to
provide this information can result in a refusal of service. You may consult, correct or obtain a copy of any personal information concerning you.
For more information, consult the Policy on Privacy on the SAAQ’s website at saaq.gouv.qc.ca or contact the SAAQ’s call centre.
Registration
(Cont’d overleaf)
Notice to readers: is document complies with Québec government standard S G Q R I 0 0 8 - 0 2 on the accessibility of downloadable documents. If you experience
diculties, please contact us at: 1 800 3 6 1 – 7 6 2 0.
LAST NAME FIRST NAME
YOUR FILE NUMBER
STREET NUMBER STREET NAME APARTMENT
MUNICIPALITY PROVINCE
POSTAL CODE
The assessment cannot begin until the applicable fees have been paid. Fees are non-refundable and subject to
change without prior notice.
Given that there may be a waiting list, we suggest that you register for your assessment as soon as possible.
For additional information concerning the assessment request,
Please note that the SAAQ informs you in writing of the type of assessment you are required to undergo.
For additional information about the CIUSSS du Centre-Sud-de-l’Île-de-Montréal or your assessment,
Québec area: 418 643-5506
Elsewhere in Québec: 1 800 561-2858
saaq.gouv.qc.ca
Send your registration form and your payment,*
which must be a certified cheque or money order made
out to the CIUSSS du Centre-Sud-de-l’Île-de-Montréal,
to the address on the right:
CIUSSS du Centre-Sud-de-l’Île-de-Montréal
950, rue de Louvain Est
Montréal (Québec) H2M 2E8
*Please refer to the letter you were sent to nd out which assessment you must register for. The table on the back of this
form provides the cost for each type of assessment.
You must register by mail
Other payment options may eventually be added. Up-to-date information on payment options can be found online at
perrcca.gouv.qc.ca (website in French only). You may also consult this website to verify whether your payment has been
received by the CIUSSS du Centre-Sud-de-l’Île-de-Montréal. Please allow a period of 15 business days for this information
to become available.
Important: If the address you have entered above is a new address, please be sure to contact the SAAQ to change your address
(if you have not already done so).
please contact the CIUSSS at: 1 888 385-0046.
please contact the SAAQ at one of the following numbers:
PHONE NUMBER (HOME) PHONE NUMBER (WORK) EXTENSION EXTENSIONPHONE NUMBER (OTHER)
