Government of Ontario

Licence Appeal Tribunal

15 Grosvenor Street, Ground Floor,
Toronto ON  M7A 1N3
Phone: 416-326-1356
Toll Free: 1-888-444-0240
Email: LATregistrar@ontario.ca
Website: tribunalsontario.ca/lat

Notice of Appeal -
Registration, Certificate, Licence, Claim Denial, Order

Important Information

• You must complete all sections of this form and attach additional information and/or documents as required.
• The processing of your appeal could be delayed if information or documents are missing.
• There is a non-refundable fee of $100 to file this appeal.
• You have the right to a representative. If you have a representative, have them complete the Tribunal's 'Declaration of Representative' form and attach it to this form.

Reasons You are Making this Appeal:
Describe in detail the points of the decision/order/proposal that you disagree with and provide details explaining why you disagree with those points. (Attach additional pages if you need more space.)

Acknowledgement - Read carefully then check each box to confirm the statement and sign and date the form.

I have completed all pages of this form and attached all the required documentation. I understand that if I submit an incomplete form or do not attach required documents, my appeal may not be processed.
I have served a copy of page 1 and 2 of this form and all additional attached documents to the Registrar of the agency that issued the decision/order/proposal I am appealing. I have attached a completed 'Certificate of Service' to this form as proof of service of the documents on the Registrar. (Blank 'Certificate of Service' forms are available on the Tribunal's website at tribunalsontario.ca/lat)
I have completed the 'Payment Information' section on page 3 of this form and am submitting payment for my appeal in an acceptable format. (Do not serve a copy of page 3 with your disclosure documents to the Registrar of the agency that issued your decision/order/proposal. Your payment information should only be provided to the Licence Appeal Tribunal.)

Print Name
Signature

Date (yyyy/mm/dd)

The following section is not part of your disclosure to the other parties. Submit this page to the Tribunal only.

Payment Information:

• Payment of $100 must be submitted with this form in one of the acceptable formats below.
• The filing fee is per licence. If you are filing an appeal about more than one licence, ensure you have submitted payment for each one.
• Money Orders, Bank Drafts and Certified Cheques must be made payable to the Minister of Finance.

The information you provide on this sheet is confidential. It will be used to process your application, but will not be placed on your file.

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 416-326-1356 or toll-free at 1-888-444-0240.