Hazardous Materials Information Review Commission - Government of Canada

FORM 4
[Paragraph 10(1)]


APPEAL BOARD
Hazardous Materials Information Review Act

IN THE MATTER OF:
An appeal (or appeals) pursuant to section 20 of the Hazardous Materials Information Review Act by from the decision(s) of the screening officer dated , 20,in relation to claim(s) for exemption bearing Registry Number(s) .


APPEARANCE
[Hazardous Materials Information Review Act Appeal Board Procedures Regulations, Form 4, Subsection 10(1)]

APPEAL NUMBER(S):
TAKE NOTICE that the undersigned intends to participate in these proceedings as
THE CLAIMANT:
AN AFFECTED PARTY AS:
Supplier of the controlled product
Employee at the work place
Employer at the work place
Safety and health professional for the work place
Safety and health representative for the work place
Member of a safety and health committee for the work place
A person who is authorized in writing to represent
  1. a supplier of the controlled product
  1. an employer at the work place
  1. an employee at the work place, except where the person is an official or a representative of a trade union that is not certified or recognized in respect of the work place


LANGUAGE OF PREFERENCE:
ENGLISH
FRENCH

The undersigned will not be represented by counsel.
OR
The undersigned will be represented by counsel.

NAME OF COUNSEL:

ADDRESS FOR SERVICE:

TELEPHONE:

OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:
DATED AT this day of , 20.

SIGNATURE:

NAME:

FIRM:

ADDRESS:

TELEPHONE:

OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS: