APPLICATION FOR CONCILIATION OF AN ACCOUNT
I, undersigned, ______________________________________________________________________________
(first name) (last name)
(address) (office phone: ) (occupation)
(home phone: )
(1) Tick (a) or (b), where applicable:
(a) __________ On ________________________ 20_____, ________________________________________
sent to ____________________________________________________________________________________
(name of client applying for conciliation)
an account in the amount of $___________________, for professional services. A copy of the account is attached hereto.
(b) __________ On ________________________ 20_____, ___________________________
I became aware that amounts were withdrawn or withheld from funds that _____________________________
holds on my behalf.
The amount of the account is $________________.
(2) Tick (a) or (b), where applicable, and give reasons:
(a) __________ I refuse to pay the account, but, where applicable, I acknowledge owing the amount of $________________.
(b) __________ I am requesting a reimbursement of $________________.
Reasons (for a or b)
(3) I am applying for conciliation by the syndic under Division I of the Regulation respecting the conciliation and arbitration procedure for the accounts of members of the Ordre professionnel des technologues professionels du Québec (chapter C-26, r. 263), of which I declare having received a copy and taken cognizance.
Sworn or solemnly affirmed before me at ________________ on this ____ day of _________________ 20_____
(Commissioner for oaths)