Office of the Procurement Ombudsman
www.boa-opo.gc.ca
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Request for Alternative Dispute Resolution
Protected « B » when completed
Provision of the information requested on this form is required in accordance with Procurement Ombudsman Regulations made under the Department of Public Works and Government Services Act for an alternative dispute resolution process to be requested to resolve disputes with respect to the interpretation or application of a contract's terms and conditions. This personal information will be stored in Personal Information Bank Number PWGSC PPU 001 and is protected from disclosure to unauthorized persons/agencies pursuant to the provisions of the Privacy Act. Under the Privacy Act you have the right to request access to your personal information, held by a federal government institution, and to request corrections should you believe the information contains errors or omissions. Personal information that you provide about another individual may be accessible to that person under the Privacy Act. The information will be retained by the Office of the Procurement Ombudsman for two years following the last administration change and then destroyed.
- Names of the parties to the Contract:
- Include a copy of the Contract.
- Provide a brief summary of the facts:
- Issue(s) in dispute:
- My position:
- My interests:
- Issues agreed upon by the parties:
- Issues upon which the parties disagree:
- Last settlement offer (if any):
Declaration
I declare and certify that the information provided herein is to the best of my knowledge true, accurate and complete.
I agree to bear the costs of my own participation in the ADR process, such as travel. Should there be costs associated with a specific type of ADR process, I will share those costs on an agreed-to basis.
Name (print):
Title (print):
Signature:
Date:(yy/mm/dd)
Telephone:
Fax (optional):
E-mail (optional):
