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/

Notice of Appeal – Suspension or Cancellation of a Driver's Licence for Medical Reasons

Under s. 47(1)(b) and s. 50 of the Highway Traffic Act

Important Information

Appellant Name and Contact Information:



Address








Do you have an Ontario driver's licence?



Information about the Decision you are Appealing:


Reasons You are Making this Appeal:


Acknowledgement

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




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

Payment Information:

Acceptable Methods of Payment:
If you are filing your appeal... You must pay by...
by fax credit card
by mail or courier credit card
certified cheque
money order
bank draft

I am paying my $100 filing fee by:






* If you are paying by credit card, you must provide the following information:







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.

For Licence Appeal Tribunal Office Use Only:


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 at 416-327-6500 or toll-free at 1-844-242-0608.

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02025E (2019/06)      © Queen’s Printer for Ontario, 2019