C-26, r. 145 - Regulation respecting the procedure for the conciliation and arbitration of accounts of members of the Ordre des hygiénistes dentaires du Québec

Schedule Disposition versions

2012-09-01

SCHEDULE I

(s. 8)

APPLICATION FOR ARBITRATION OF AN ACCOUNT

I, the undersigned, ____________________________________________________________________

(applicant’s name and first name)

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(address) (occupation)

declare that:

(1) As on ______________________________ (date), ______________________________ (name of member) sent to ______________________________(name of client applying for arbitration) an account in the amount of $____________________, for professional services.

(2) Mark a or b as applicable:

(a) I am the client applying for arbitration;

(b) I am the advocate of the client applying for arbitration and I am duly authorized, under an authorization a copy of which is attached hereto, to sign this form on his behalf.

(3) Mark a or b as applicable and give reasons:

(a) I refuse to pay the account;

(b) I am asking for a reimbursement of $____________________;

Reasons: ____________________________________________________________________________

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(4) During conciliation, I acknowledged owing the amount of $____________________ and consequently I am depositing with this application a certified cheque to the order of the Secretary of the Ordre des hygiénistes dentaires du Québec “in trust”.

(5) I have enclosed a copy of the conciliation report.

(6) I am applying for arbitration of the account under the Regulation respecting the procedure for the conciliation and arbitration of accounts of members of the Ordre des hygiénistes dentaires du Québec (chapter C-26, r. 145).

(7) I have received a copy of the Regulation mentioned above and have taken cognizance thereof.

(8) I agree to submit to the procedure provided for in that Regulation and to the ensuing arbitration award.

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Date Signature

O.C. 675-96, Sch. I.