Government of Ontario

Pay Equity Commission
180 Dundas St W Suite 300
Toronto On M7A 2S6
416 314-1896 or 1 800 387-8813
TTY: 416 212-3991 or 1 855 253-8333
Fax: 416 314-8741

Application for Review Service

Note: Please answer all questions and submit your application by mail, email, fax or in person.
Please type or print clearly in ink. You may add additional pages if space is insufficient.

Submit this Application:
Pay Equity Commission
Pay Equity Office
180 Dundas St W Suite 300
Toronto On M7A 2S6
416-314-1896 or 1 800-387-8813
TTY: 416-212-3991 or 1 855 253 8333
Email: PayEquityComplaint@ontario.ca

All 5 Parts Must be completed

Part 1 – Who is Applying: (Provide Names, Addresses and Telephone #s of any Additional Applicants on a Separate List)

Are You: (Check All that Apply)

An Individual Employee
In a Union
A Group of Employees*
Not in a Union
An Agent Acting for Employee(s)
An Employer OR A Union

*If applying on behalf of a group of employees, provide the names, addresses and signatures of the group of employees. (Use additional pages)

Applicant Last Name
Applicant First Name
Middle Initial
What is your Job Title:

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Home Telephone No. (incl. area code)
Work Telephone No. (incl. area code) Work Telephone No. Ext.
Cell No.
Fax No.
Email Address

Name and Job Title of Person to Contact about
this Application

Last Name
First Name
Middle Initial
Job Title
Contact Home Telephone No. (incl. area code)
Work Telephone No. (incl. area code) Work Telephone No. Ext.

Part 2 - Employer

Name of Employer
Type of Business/Organization

Name and Job Title of Person to Contact

Last Name
First Name
Middle Initial
Job Title

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Work Telephone No. (incl. area code) Work Telephone No. Ext.
Fax No.
Email Address

Part 3 – Union/Association/Labour Organization (If Applicable)

Name

Name and Job Title of Person to Contact

Last Name
First Name
Middle Initial
Job Title

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Work Telephone No. (incl. area code) Work Telephone No. Ext.
Fax No.
Email Address

Part 4 – Why Are You Applying

Why Are You Applying

Pay equity was not done
I don’t know if Pay Equity was done
Pay equity is not being maintained in the organization
I disagree with the results of pay equity
I have been fired, harassed, or I suffered a penalty because of pay equity
Employer and Union cannot reach an agreement on pay equity
Pay equity is not being carried out as stated in the plan
There has been a violation of the Act, the Regulations or an Order of the Commission
Other Other (Please Specify):

Provide a description about your complaint. (Use additional pages, if necessary. You may attach any documents that you have):

Part 5 – Anonymous

If you do not wish to be identified by your employer, you may choose to remain anonymous. To file an anonymous complaint, you must arrange for an individual to act as your agent. All communication will be done through the agent.

Name of agent who will act on your behalf

Mailing Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Work Telephone No. (incl. area code) Work Telephone No. Ext.
Fax No.
Email Address

The information is collected under the authority of the Pay Equity Act, 1987 for the purposes of this enforcement. For information concerning the collection and use of this information, please contact Legal Counsel, Pay Equity Office, at the following address: Pay Equity Commission: Pay Equity Office, 180 Dundas St W Suite 300, Toronto On M7A 2S6, 416 314-1896 or 1 800 387-8813, TTY: 416 212-3991 or 1 855 253-8333, Fax: 416 314-8741.

Please Print

Last Name
First Name
Signature

Date (yyyy/mm/dd)

For Office Use Only

Date Received (yyyy/mm/dd)
Form Telephone Email Letter Fax
Received By
File Number