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

(name person)

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

(a)	a supplier of the controlled product

(b)	an employer at the work place

(c)	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:	_______________________________________________

(print)

FIRM:	_______________________________________________

ADDRESS:	_______________________________________________

_______________________________________________

TELEPHONE:	_______________________________________________

OTHER MEANS OF TELECOMMUNICATIONS

AND THEIR NUMBERS:	_______________________________________________