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D-4, r. 12 - Regulation respecting the conciliation and arbitration procedure for the accounts of members of the Ordre des denturologistes du Québec

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SCHEDULE I
(s. 8)
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 denturologistes du Québec (chapter D-4, r. 12).
(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.
________________________________________________
Signature
O.C. 1362-94, Sch. I.
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