APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, ____________________________________________________________________
(name of the client)
(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)