APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, __________(name and address of patient)__________
Declare under oath that:
(1) ______________________________ has claimed from me (or refuses to refund to me) a sum of money for professional services.
(2) I have enclosed a copy of the conciliation report and (where applicable) a certified cheque made out to the Order in the amount of $ __________, which amount I acknowledge owing and is indicated in the conciliation report.
(3) I am applying for arbitration of the account under Division III of the Regulation respecting the conciliation and arbitration procedure for the accounts of acupuncturists (chapter A-5.1, r. 7), a copy of which I have received and have taken cognizance.
(4) I agree to abide by the procedure provided for in the Regulation and, where required, to pay to __________(name of acupuncturist)__________ the amount of the arbitration award.
And I have signed Oath taken before
(name and function, profession, or capacity)
on _____________________________________ at ______________ on ________________
(date) (place) (date)
(signature of patient) (signature)