APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned, __________(client’s name)__________ __________(domicile)__________ declare that:
(1) __________(member’s name)__________ 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 members of the Ordre des optométristes du Québec (chapter O-7, r. 16).
(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.