Government of Ontario

Licence Appeal Tribunal

530 – 20 Dundas Street West
Toronto ON  M5G 2C2
Phone: 416 314-4260
Toll Free: 1 800 255-2214
Fax: 416 314-4270
Toll Free: 1 800 720-5292

Supporting Documentation – Administrative Driver's Licence Suspension – Applicant's Medical Information

Under s.48.3 and s. 50.1 of the Highway Traffic Act

IMPORTANT INFORMATION FOR THE APPLICANT:

IMPORTANT INFORMATION FOR THE DOCTOR:

Applicant Name and Contact Information:



Address












How long has the applicant been your patient? or .

Physician's information:





Address








The Licence Appeal Tribunal collects the personal information requested on this form under section 3 of the Licence Appeal Tribunal Act, 1999. This information will be used to determine applications under this Act. After an application is filed, all information may become available to the public. Any questions about this collection may be directed to the Licence Appeal Tribunal at 416 314-4260 or toll-free at 1 800 255-2214.

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02053E (2012/06)      © Queen’s Printer for Ontario, 2012