Licence Appeal Tribunal
PO Box 250
Toronto ON M7A 1N3
Toll Free: 1-844-242-0608
Toll Free: 1-844-618-2566
Licence Appeal Tribunal file No.
Time including AM/PM (hh:mm)
Reason for this Request to Adjourn:
Consent to the adjournment *
Do not consent to the adjournment
* If all parties consent to this adjournment, provide three dates within the next 30 days that all parties are
available to attend. If all parties do not consent, provide three dates in the next 30 days, you the requestor
are available to attend.
1. Date (yyyy/mm/dd)
2. Date (yyyy/mm/dd)
3. Date (yyyy/mm/dd)
Important: For matters with multiple parties, attach any additional signatures on a separate page.
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
3047E (2019/08) © Queen’s Printer for Ontario, 2019
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