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
Website: www.slasto-tsapno.gov.on.ca/lat-tamp/en/

Declaration of Representative

LAT Office Use Only
File No.

Important Information

If you have a representative for a matter before the Tribunal, have them fill in this form clearly and completely and provide it to the Tribunal and all other parties immediately.
You must also notify the Tribunal and all parties in writing if the representative you name stops representing you and you find a new representative, or you decide to represent yourself.
Only persons licensed by the Law Society of Upper Canada (LSUC) or who fall within the exceptions or exemptions approved by the LSUC may represent a party before the Tribunal.
For the current list of exemptions for unlicenced representatives, visit the LSUC website at www.lsuc.on.ca or contact them at 416 947-3300 or toll-free 1-800-668-7380.

Representative Information:

Last Name
First Name
Initial
Company Name

Address:

Street No. and Name, Unit No.
City
Province
Postal Code

Phone No.
Fax No.

Declaration of Representative:

I am representing
Name of Party: Last Name
Name of Party: First Name

Before the Licence Appeal Tribunal in the matter of
Name of Appellant: Last Name
Name of Appellant: First Name
and
Name of Respondent: Last Name
Name of Respondent: First Name

Acknowledgement: (check one)

I acknowledge that I am licensed by the Law Society of Upper Canada (LSUC) to provide legal services.
My LSUC No. is
I acknowledge I am an unlicensed representative covered by an exemption allowed by the LSUC.
The exemption I fall under is

Print Name
Signature of Representative

Date (yyyy/mm/dd)

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.