C-26, r. 220 - Regulation respecting the conciliation and arbitration procedure for the accounts of psychologists

Schedule Disposition versions

2012-09-01

SCHEDULE III

(ss. 8 and 10)

APPLICATION FOR ARBITRATION OF AN ACCOUNT

I, the undersigned, ____________________________________________________________________

(name of the client)

---

(domicile)

declare that:

(1) __________(name of the psychologist)__________ is claiming from me (or refuses to reimburse me) a sum of money for professional services.

(2) I have enclosed a copy of the conciliation report and, where applicable, a certified cheque payable to the psychologist, in the amount of ______________________________, which represents the sum of money that I acknowledge owing and that is stated in the conciliation report.

(3) I am applying for arbitration of the account under the Regulation respecting the conciliation and arbitration procedure for the accounts of psychologists (chapter C-26, r. 220).

(4) I have received a copy of the above Regulation and have taken cognizance thereof.

(5) I agree to submit to the procedure provided for in the Regulation and, where required, to pay to __________(name of the psychologist)__________ the amount of the arbitration award.

Signed on __________________________________________________________________________

(signature of the client)

O.C. 145-2000, Sch. III; O.C. 246-2000, s. 1.