C-26, r. 263 - Regulation respecting the conciliation and arbitration procedure for the accounts of members of the Ordre professionnel des technologues professionnels du Québec

Schedule Disposition versions

2012-09-01

SCHEDULE I

(ss. 1 and 2)

APPLICATION FOR CONCILIATION OF AN ACCOUNT

I, undersigned, ______________________________________________________________________________

(first name) (last name)

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(address) (office phone: ) (occupation)

(home phone: )

declare that:

(1) Tick (a) or (b), where applicable:

(a) __________ On ________________________ 20_____, ________________________________________

(date) (technologist)

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_____, ___________________________

(date)

I became aware that amounts were withdrawn or withheld from funds that _____________________________

(technologist)

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)

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(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.

Signed ______________________________________

(client’s signature)

Sworn or solemnly affirmed before me at ________________ on this ____ day of _________________ 20_____

_______________________________________

(Commissioner for oaths)

O.C. 1241-93, Sch. I.