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S-0.1, r. 16 - Regulation respecting the conciliation and arbitration procedure for the accounts of midwives
Schedule
Disposition versions
SCHEDULE I
(ss. 8 and 9)
APPLICATION FOR ARBITRATION OF AN ACCOUNT
I, the undersigned __________(name of woman)__________ __________(domicile)__________ declare that
(1) __________(name of member of the Order)__________ is claiming from me (or refuses to refund to me) a sum of money for professional services.
(2) I have enclosed a copy of the conciliation report and, where applicable, a certified cheque to the member of the Ordre des sages-femmes du Québec representing the amount that I acknowledge owing and indicated in 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 midwives (chapter S-0.1, r. 16).
(4) I have received a copy of the Regulation mentioned above and have taken cognizance thereof.
(5) I agree to abide by the procedure provided for in the Regulation and, where required, to pay to __________(name of member)__________ the amount of the arbitration award.
