Licence Appeal Tribunal
PO Box 250
Toronto ON M7A 1N3
Toll Free: 1-844-242-0608
Toll Free: 1-844-618-2566
Company Operating Name (if applicable)
Numbered Company Name (if applicable)
Street No. and Name, Unit No.
Date Issued (yyyy/mm/dd)
As required, I have attached a copy of the decision/order/proposal I am appealing.
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 www.slasto-tsapno.gov.on.ca/lat-tamp/en/)
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.)
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 Number
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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