Licence Appeal Tribunal
PO Box 250
Toronto ON M7A 1N3
Toll Free: 1-844-242-0608
Toll Free: 1-844-618-2566
Date Issued (yyyy/mm/dd)
As required, I have attached a copy of the decision I am appealing.
Describe in detail the points of the decision that you disagree with and provide details explaining why you disagree with those points. Include any written documents in support of your appeal that you wish to refer to at the hearing, including any medical reports, test results, etc. If you cannot include them with your notice of appeal, be sure to forward them to the Tribunal and to the Registrar in accordance with the requirements of Rule 6 of the Tribunal’s Rules of Practice.
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 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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