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)
Address: Street No. and Name, Unit No.
Information about the Decision / Order / Proposal You are Appealing:
Date Issued (yyyy/mm/dd)
As required, I have attached a copy of the decision/order/proposal I am appealing.
I am filing my appeal within the deadline indicated on the decision/order/proposal.
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.)
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 this form and am submitting payment for my appeal in an acceptable format. (Do not serve a copy of the 'Payment Information' section with your disclosure documents to the Registrar of Alcohol and Gaming. Your payment information should only be provided to the Licence Appeal Tribunal.)
I have served a copy of page 1 and 2 of this form and all additional attached documents to the Registrar of the Alcohol and Gaming Commission of Ontario. 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 am paying my $100 filing fee by:
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.
Disponible en français
02027E (2019/06) © Queen’s Printer for Ontario, 2019