NAME OF APPELLANT:
	ADDRESS:
	CITY:
	PROVINCE:
	POSTAL CODE:
	ADDRESS FOR SERVICE: (if different from above)
	CONTACT PERSON: (where appellant is a corporation)
	TITLE:
	ADDRESS FOR SERVICE:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
	COUNSEL (if any):
	FIRM:
	ADDRESS FOR SERVICE:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
	LANGUAGE OF PREFERENCE:
	ENGLISH	[  ]
	FRENCH	[  ]

• NOTE: 

  This Part seeks information in respect of the status of the person filing the statement of appeal. Please check opposite the description of that status.

• NOTE: 

  This Part seeks information that will identify the class or nature of the appeal being filed. Please put a check mark opposite the most appropriate statement or statements.

• NOTE: 

  This Part seeks information that will assist in determining the place where the appeal will be convened and the manner in which the appeal board will be constituted.

(a)	Where the claimant carries on business in one province only, name the province:
(b)	Where the claimant carries on business in more than one province, name the province most directly concerned with the question under appeal and explain why that province is the province that is most directly concerned with the question under appeal:

PROVINCE:
EXPLANATION:

• NOTE: 

  This Part seeks information that will delineate the basis and the scope of the appeal.

The information provided should identify in point form the alleged errors in the screening officer’s decision, order or undertaking. Attach additional sheets if necessary.

• NOTE: 

  This Part should provide detailed information in support of the appeal, including reasons and any facts or information that may assist the appeal board in understanding the representations made in respect of the appeal and in deciding the appeal. Attach additional sheets if necessary.

• NOTE: 

  This Part provides the appellant with the opportunity to indicate whether the appellant wishes to appear before the appeal board for the purpose of making oral submissions or examining witnesses.

(a)	The appellant wishes to appear before the appeal board for the purpose of making oral submissions		[  ] YES	[  ] NO
(b)	The appellant is of the opinion that there are material issues of fact or opinion, the nature of which requires the examination of witnesses		[  ] YES	[  ] NO
	If the answer to paragraph (b) is yes, the appellant’s reasons for the opinion are as follows:

• NOTE: 

  Subsections 23(2) and (3) of the Act provide as follows:

  • “(2) An appeal board may dispose of an appeal of a decision or an order by

    • (a) dismissing the appeal and confirming the decision or order of the screening officer; or

    • (b) allowing the appeal and either varying or rescinding the decision or order being appealed.

  • (3) An appeal board may dispose of an appeal of an undertaking by

    • (a) dismissing the appeal; or

    • (b) allowing the appeal and making any order that the appeal board considers appropriate.”

This Part seeks a brief statement describing the nature of the decision or order that the appellant requests that the appeal board make.

DECISION OR ORDER SOUGHT:

• NOTE: 

  Where the appellant makes an application under section 26 of the Act for the disclosure in confidence, for reasons of health and safety in a work place, of information in respect of which a claim for exemption is made, the appellant may include the application for disclosure in this Part or complete Form 2.

The application shall contain a full statement of the reasons, facts and circumstances supporting the application. The application shall state the order that is sought, including the names of the affected parties or the class of affected parties to whom disclosure of the confidential business information is sought. Attach additional sheets if necessary.

APPLICATION FOR DISCLOSURE:

• NOTE: 

  The appellant may place confidential information in this separate part of the Statement of Appeal and shall mark each sheet of confidential information with the word “Confidential/Confidentiel”.

CONFIDENTIAL/CONFIDENTIEL:

• NOTE: 

  Where the appellant is the claimant and the Statement of Appeal will identify or disclose any confidential business information in respect of which the claim for exemption has been made, the appellant shall place that information in this separate part of the Statement of Appeal and file it in a sealed envelope separate from but together with the other parts of this Statement of Appeal. Each sheet of such information and the envelope shall be marked with the words “Confidential Business Information/Renseignements confidentiels commerciaux”.

CONFIDENTIAL BUSINESS INFORMATION/RENSEIGNEMENTS CONFIDENTIELS COMMERCIAUX:

I, (name), hereby certify on behalf of the appellant herein that the information reported in Parts I to XI of this Form is true to the best of my knowledge and belief.

(Signature)(Date)

(Title)

	NAME OF APPLICANT:
	ADDRESS:
	CITY:
	PROVINCE:
	POSTAL CODE:
	ADDRESS FOR SERVICE: (if different from above)
	CONTACT PERSON: (where applicant is a corporation)
	TITLE:
	ADDRESS FOR SERVICE:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS
	COUNSEL (if any):
	FIRM:
	ADDRESS FOR SERVICE:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
	LANGUAGE OF PREFERENCE:
	ENGLISH	[  ]
	FRENCH	[  ]

• NOTE: 

  This Part seeks information in respect of the status of the person filing the application. Please check opposite the description of that status.

In relation to the decision or the order of a screening officer referenced by the present applicant, the applicant is

Provide the name and address of the employer or supplier that has the confidential business information that is the subject of the application.

Where the employer or supplier carries on business in one province, name the province:

Where the employer or supplier carries on business in more than one province, name the province most directly concerned with the application and explain why the province is the province that is most directly concerned with the application:

PROVINCE:
EXPLANATION:

State the order that is sought, including the names of the affected parties or the class of affected parties to whom disclosure of the confidential business information is to be made.

• NOTE: 

  Section 26 of the Act permits an appeal board to make an order for disclosure, in confidence, of confidential business information to named affected parties or each member of a class of affected parties. The order may be made for reasons of health and safety in a work place.

Provide a full statement of the reasons, facts and circumstances supporting the application. Attach additional sheets if necessary.

• NOTE: 

  The applicant may place confidential information in this separate part of the application and shall mark each sheet of confidential information with the word “Confidential/ Confidentiel.”

CONFIDENTIAL/CONFIDENTIEL:

Appeal or Application number

An appeal has been commenced by (name) from the decision, order or undertaking of a screening officer dated , 19, in relation to a claim for exemption made by (name) bearing Registry Number . The decision, order or undertaking appealed from provided that (include a brief summary of the decision, order or undertaking):

The appellant states that (include a brief summary of the grounds of appeal):

AND

(Where the appeal includes an application)

The appellant has applied, pursuant to subsection 26(1) of the Hazardous Materials Information Review Act, for an order requiring the claimant to disclose, in confidence, confidential business information to affected parties. The appellant states that (include a brief statement of the reasons for the application):

OR

(Where there is no appeal)

An application has been made by (name) pursuant to subsection 26(1) of the Hazardous Materials Information Review Act for an order requiring (name of claimant) to disclose, in confidence, confidential business information to affected parties. The applicant states that (include a brief statement of the reasons for the application):

The appeal or the application, or both, will be heard by an appeal board consisting of , Chairman, and and , Members.

Any affected party or the claimant, where the claimant is not the appellant, who intends to participate in the appeal or application or in both shall advise the appeal board by filing an Appearance with the appeal board and serving a copy of the Appearance on the appellant or the applicant on or before (date).

The address for service on the appellant or applicant is:

	ADDRESS:
	TELEPHONE :
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
Copies of the form of Appearance as well as information as to appeal board procedures may be obtained from the Office of the Chief Appeals Officer at:
	NAME OF CHIEF APPEALS OFFICER:
	HAZARDOUS MATERIALS INFORMATION REVIEW COMMISSION ADDRESS:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
	Dated at Ottawa this day of 19.
		Chief Appeals Officer

	NAME OF COUNSEL:
	ADDRESS FOR SERVICE:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
Dated at , this day of 19 .
	SIGNATURE :
	NAME: (print):
	FIRM:
	ADDRESS:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:

Appeal or Application number:

I hereby affirm that

(a) I am

(i) in the case of counsel, a member of the Bar of (province), or

(ii) in the case of an expert who assists the counsel, a person possessing expertise in (specify area of expertise);

(b) I am ordinarily resident in Canada;

(c) I am not an employee, officer, director or major shareholder of any party to the proceedings or of any corporation controlled by such a party;

(d) I am not an employee, officer or representative of a union association; and

(e) I do not have any personal interest that could influence, or reasonably appear to influence, the exercise of my duties with respect to these proceedings.

I hereby promise to comply with the following requirements:

(a) I will not disclose any confidential information that I obtain in the course or as a consequence of these proceedings to any person who is not authorized pursuant to the Hazardous Materials Information Review Act Appeal Board Procedures Regulations to have access to confidential information;

(b) I will not reproduce in any manner, without the prior approval of the appeal board, any document or other material that I obtain in the course or as a consequence of these proceedings that is or contains confidential information; and

(c) I will return to the Chief Appeals Officer any document or other material that contains confidential information that I obtain in the course or as a consequence of these proceedings before the later of

(i) the 30th day after the decision of the appeal board, and

(ii) the expiration of any period for commencing further proceedings in respect of the appeal board’s decision.

I appear, in the case of counsel, as counsel for (name),

a party before the appeal board in these proceedings; or, in the case of an expert who assists the counsel, I am assisting counsel for (name),

a party before the appeal board in these proceedings.

Dated at this day of , 20.

	SIGNATURE:
	NAME: (print)
	FIRM:
	ADDRESS:
	TELEPHONE:
	OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:

WARNING: Access to confidential information is provided only in accordance with the Hazardous Materials Information Review Act Appeal Board Procedures Regulations, which are regulations made under the authority of the Hazardous Materials Information Review Act. Section 49 of that Act provides as follows:

• • “49. (1) Every person who contravenes or fails to comply with any provision of this Part or any regulation or order made under this Part

    • (a) is guilty of an offence punishable on summary conviction and liable to a fine not exceeding one hundred thousand dollars or to imprisonment for a term not exceeding six months or to both; or

    • (b) is guilty of an indictable offence and liable to a fine not exceeding one million dollars or to imprisonment for a term not exceeding two years or to both.

  • (2) Where a corporation commits an offence under subsection (1), any officer, director or agent of the corporation who directed, authorized, assented to, acquiesced in or participated in the commission of the offence is a party to and guilty of the offence and is liable on conviction to the punishment provided for the offence whether or not the corporation has been prosecuted or convicted.

  • (3) Proceedings by way of summary conviction in respect of an offence under paragraph (1)(a) may be instituted at any time within but not later than twelve months after the time when the subject-matter of the proceedings arose.”

Appeal or Application number:

The undersigned hereby certifies that a copy of the attached document (or, where the document has already been filed, describe the document, e.g. the “Statement of Appeal”) has been served on each person entitled to service thereof, as follows: (list persons)

OR
(Where the document contains confidential information)
The undersigned hereby certifies that
	(a) a copy of the attached document (or, where the document has already been filed, describe the document, e.g. the “Statement of Appeal”), including any confidential information contained therein, has been served on each person entitled to service thereof, as follows: (list persons)
	and
	(b) the said document, excluding any confidential information, has been served on each person entitled to service thereof, as follows: (list persons)
		(Name)

TO:
You are hereby required to attend before the Appeal Board at the of in the Province of on the day of , 19, at the hour of o’clock in the noon and thereafter, from day to day until the above matter is heard, to give evidence on behalf of and also to bring with you and produce at the time and place aforesaid the following documents: (specify documents)
For your appearance you will receive
(a) travelling expenses, if any, in the amount of $; and
(b) where applicable, professional fees in the amount of $.
IN WITNESS WHEREOF this Subpoena is signed for the Appeal Board at , this day of , 19.
		Chief Appeals Officer (or Chairman of the Appeal Board)

(The following shall be endorsed on the Subpoena.)

• NOTE: 

  Subsections 20(2) and (3) of the Hazardous Material Information Review Act Appeal Board Procedures Regulations provide as follows:

  • “(2) No person is required to appear before the appeal board pursuant to a subpoena unless, at the time of service of the subpoena on the person, the appeal board that on its own instance issued the subpoena or the party who requested the subpoena has paid or tendered to the person conduct money in an amount sufficient for the person’s reasonable travelling expenses and professional fees, if any.

  • (3) Where a person who is served with a subpoena disputes the reasonableness of any conduct money paid or tendered, the person shall advise the appeal board of the dispute, and the appeal board, after hearing the submissions of the person and the party who requested the subpoena, may fix the amount of the conduct money or the manner in which the conduct money is to be calculated.”

The appeal board can be contacted through the office of the Chief Appeals Officer at:

NAME OF CHIEF APPEALS OFFICER:
HAZARDOUS MATERIALS INFORMATION REVIEW COMMISSION ADDRESS:
TELEPHONE:
OTHER MEANS OF TELECOMMUNICATIONS, AND THEIR NUMBERS: