APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, __________(client’s name or name of his mandatary)__________ __________(domicile)__________ declare that:
(1) __________(member’s name)__________ is claiming from me (or refuses to reimburse to me) a sum of money in the amount of $__________ 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 members of the Ordre des comptables professionnels agréés du Québec (chapter C-48.1, r. 27).
(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 __________(member’s name)__________ the amount of the arbitration award.
I, the undersigned, __________(name and address)__________ in my own name or, if applicable, as a representative of ______________________________ as witnessed by the mandate which is attached to this application for arbitration, do hereby swear that this application for arbitration is made in good faith and not with intent to unduly delay payment.
And I have signed:
__________(signature of the client or his duly authorized representative)__________
Sworn before me at ______________________________ this __________ day of ______________________________ 20 __________
Commissioner for oaths