Government of Ontario

Tribunals 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

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

Important Information

Appellant Name and Contact Information:


Information about the Decision / Order / Proposal
You are Appealing:

I am filing my appeal within the deadline
indicated on the decision/order/proposal.


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

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.)

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 $106 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 416-327-6500 or toll-free at 1-844-242-0608.