Hazardous Materials

Information Review Act Appeal

Board Procedures Regulations	FORM 5

[Subsections 7(4), 12(4) and 35(2)]

APPEAL BOARD

HAZARDOUS MATERIALS INFORMATION REVIEW ACT

IN THE MATTER OF:	An appeal pursuant to section 20 of the Hazardous Materials Information Review Act by __________________________________________________ from the decision of the

(name person)

screening officer dated ____________________, 20___, in relation to a claim for exemption bearing Registry Number ______________.

OR

An application for an order pursuant to subsection 26(1) of the Hazardous Materials Information Review Act by __________________________________________________

(name person)

DECLARATION AND UNDERTAKING

APPEAL OR APPLICATION NUMBER: ______________

I hereby declare that

(a)	I am

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

(province)

(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 related persons1; and

(d)	I am not an employee, official or a representative of a union association.

I hereby undertake that

(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 within the later of

(i)	the 30th day after the decision of the 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 the counsel, as counsel for _______________________, a party before the appeal board

(name)

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

(name)

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 the 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 and 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."