Hazardous Materials |
FORM 1 |
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APPEAL BOARD
HAZARDOUS MATERIALS INFORMATION REVIEW ACT
IN THE MATTER OF:
STATEMENT OF APPEAL
NAME OF APPELLANT: |
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ADDRESS: |
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CITY: |
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PROVINCE: |
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POSTAL CODE: |
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ADDRESS FOR SERVICE: |
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CONTACT PERSON: |
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TITLE: |
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ADDRESS FOR SERVICE: |
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TELEPHONE: |
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OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS: |
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COUNSEL (if any): |
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FIRM: |
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ADDRESS FOR SERVICE: |
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TELEPHONE: |
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OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS: |
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LANGUAGE OF PREFERENCE: |
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.
STATUS OF THE APPELLANT
In relation to the decision or the order of a screening officer referenced by the
statement of appeal, the appellant is
A CLAIMANT |
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AN AFFECTED PARTY AS: |
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Supplier of the controlled product |
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Employee at the work place |
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Employer at the work place |
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Safety and health professional for the work place |
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Safety and health representative for the work place |
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Member of a safety and health committee for the work place |
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A person who is authorized in writing to represent |
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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.
THE CLAIMANT IS |
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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.
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 or order. 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.
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NOTE: Subsection 23(2) of the Act provides as follows:
"(2) An appeal board may dispose of an appeal 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."
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:
NOTE: Appeal fees must be paid by certified cheque or money order in Canadian dollars to the Receiver General for Canada.
1. |
BASIC FEE |
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Fee required to accompany a statement of appeal pursuant to subsection 12(1) |
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2. |
FEE, OTHER THAN BASIC FEE (Please check opposite the appropriate status.) |
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Fee required pursuant to subsection 12(2) of the HIMRR to accompany a statement of appeal is one half of the basic fee where the statement of appeal is filed by: |
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(a) an affected party who is an individual employee and who is not |
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(b) an affected party who is a member, official or representative of a trade union that |
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(c) a claimant that |
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3. |
FEE ENCLOSED (Please check opposite appropriate fee.) |
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Basic Fee ($2,000) |
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Fee, other than Basic Fee ($1,000) |