Government of Ontario

Licence Appeal Tribunal

PO Box 250
Toronto ON  M7A 1N3
Phone: 416-327-6500
Toll Free: 1-844-242-0608
Fax: 416-325-1060
Toll Free: 1-844-618-2566

Declaration of Representative

Important Information

Representative Information:


Declaration of Representative:

I am representing

Before the Licence Appeal Tribunal in the matter of


Acknowledgement: (check one)

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 appeals under this Act. After an appeal is filed, all information may become available to the public. Any questions about this collection may be directed to the Licence Appeal Tribunal at 416-327-6500 or toll-free at 1-844-242-0608.