APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, __________(client’s name)__________ __________(domicile)_________ declare that:
(1) __________(name of medical imaging technologist, radiation oncology technologist or medical electrophysiology technologist)__________ is claiming from me (or refuses to reimburse to me) a sum of money for professional services.
(2) I have enclosed a copy of 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 medical imaging technologists, radiation oncology technologists and medical electrophysiology technologists (chapter T-5, r. 12).
(4) I have received a copy of the Regulation mentioned above 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 medical imaging technologist, radiation oncology technologist or medical electrophysiology technologist)__________ the amount of the arbitration award.