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Il est nécessaire d'être affilié au COS Breizh pour bénéficier des prestations.
Si vous êtes nouvellement recruté(e) par une structure adhérente, vous pouvez remplir le formulaire ci-dessous afin que votre affiliation soit prise en compte.
Avant de remplir le formulaire, il est nécessaire de télécharger et remplir manuellement les documents ci-dessous. Ceux-ci vous seront demandés à la fin de votre démarche :
En fin de formulaire, il vous sera également demandé de joindre la copie de votre livret de famille ainsi qu'un RIB.
Structure employeur
Civilité MadameMonsieur
Votre nom
Votre prénom
Votre nom de naissance
Date de naissance {"name":"Datedenaissance","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":"Datedenaissance","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}
Adresse
Code postal Ville
N° tél. mobile N° tél. fixe
Email
Marié(e) Pacsé(e) Union libre Veuf(ve) Célibataire Séparé(e) Divorcé(e)
Nom de votre conjoint
Prénom de votre conjoint
Date de naissance de votre conjoint {"name":"Datenaissanceconjoint","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":"Datenaissanceconjoint","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}
1er enfant
Nom Prénom
Date de naissance {"name":"Datenaissance1erenfant","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 Masculin Féminin
{"name":"Datenaissance1erenfant","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}
Précisez si votre enfant est à votre chargeen garde alternéehandicapénon à charge mais vous versez une pension alimentaire pour lui
2ème enfant
Date de naissance {"name":"Datenaissance2emeenfant","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 Masculin Féminin
{"name":"Datenaissance2emeenfant","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}
Précisez si votre enfant est à chargeen garde alternéehandicapénon à charge, mais vous versez une pension alimentaire pour lui
3ème enfant
Date de naissance {"name":"Datenaissance3emeenfant","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 Masculin Féminin
{"name":"Datenaissance3emeenfant","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}
Précisez si votre enfant est à chargeen garde alternéehandicapénon à charge mais vous versez une pension alimentaire pour lui
4ème enfant
Date de naissance {"name":"Datenaissance4emeenfant","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 Masculin Féminin
{"name":"Datenaissance4emeenfant","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}
Date de recutement {"name":"Daterecrutement","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":"Daterecrutement","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}
Type de contrat Agent titulaireAgent stagiaireCDD (6 mois minimum)CDIApprenti
Copie livret de famille {"name":"Livretdefamille","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739a4cf","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":"673ef2739a4cf"}}
{"name":"Livretdefamille","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739a4cf","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":"673ef2739a4cf"}}
Relevé d'identité bancaire {"name":"RIB","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739a7c7","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":"673ef2739a7c7"}}
{"name":"RIB","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739a7c7","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":"673ef2739a7c7"}}
Mandat SEPA complété {"name":"MandatSEPA","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739aa12","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":"673ef2739aa12"}}
{"name":"MandatSEPA","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739aa12","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":"673ef2739aa12"}}
Attestation employeur complétée {"name":"Attestationemployeur","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739ac31","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":"673ef2739ac31"}}
{"name":"Attestationemployeur","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739ac31","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":"673ef2739ac31"}}
Si vous êtes en CDD ou en contrat d'apprentissage, joindre la copie de votre contrat de travail {"name":"Copiecontratcdd","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739ae4a","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":"673ef2739ae4a"}}
{"name":"Copiecontratcdd","label":"Parcourir...","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"]},"size_max":"5M","multiple":false,"increment":false,"valueIsHtml":true,"label_files":"Parcourir ([total] fichier[s])","id":"673ef2739ae4a","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":"673ef2739ae4a"}}
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