APPLICATION FOR CONCILIATION
I, the undersigned __________(name and address of client)_________, declare that:
(1) __________(name and address of member)__________ is claiming from me the sum of $____________________ for professional services rendered between __________(date)__________ and __________(date)__________ as evidenced by:
the account a copy of which is attached hereto □
the document a copy of which is attached hereto, indicating that the amount has been □
withdrawn or withheld.
(2) I am contesting the account for the following reasons:
(3) I acknowledge owing the sum of $ ____________________ for the professional services mentioned in the account.
(4) (a) I have not paid the account □
(b) I have paid the account in full □
(c) I have paid a portion of the account, in the amount of $____________________ □
(d) The sum of $____________________ has been withdrawn or withheld directly from the funds the member holds or has received for or on my behalf. □
(5) I am applying for conciliation by the syndic under the Regulation respecting the procedure for the conciliation and arbitration of accounts of members of the Ordre des conseillers et conseillères d’orientation et des psychoéducateurs et psychoéducatrices du Québec (chapter C-26, r. 75).
And I have signed on _________________________________________________________________