Licence Appeal Tribunal
PO Box 250
Toronto ON M7A 1N3
Toll Free: 1-844-242-0608
Toll Free: 1-844-618-2566
Date of Birth (yyyy/mm/dd)
Check only one of the following grounds of appeal and attach any supporting materials with this form:
This is a case of mistaken identity. I am not the same individual to whom a demand was made, or from whom a sample was taken, under section 254 of the Criminal Code (Canada).
II was unable to comply with a demand made under section 254 of the Criminal Code (Canada) for a medical reason. (If you are applying on this ground you should have your doctor complete the Applicant’s Medical Information form and submit it with this Notice of Appeal).
Date Issued (yyyy/mm/dd)
As required, I have attached a copy of the decision I am appealing.
I am filing my appeal within the deadline indicated on the decision.
Describe in detail the points of the order that you disagree with and provide details explaining why you disagree with those points.
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.
In accordance with Rule 4 of the Tribunalís Rules of Practice, I have served a copy of page 1 and 2 of this form and all additional attached documents to the Registrar of Motor Vehicles. 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
I have completed the 'Payment Information' section on page 3 of this form and am submitting payment for my appeal in an acceptable format.
* If you are paying by credit card, you must provide the following information:
Expiry Date (mm/yyyy)
Credit Card Number
Cardholder Name (as it appears on card)
The information you provide on this sheet is confidential. It will be used to process your application, but will not be placed on
LAT File No.
Date Appeal and Fee Processed
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.
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