Hazardous Materials Information Review Commission - Government of Canada

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 screening officer dated , 20, in relation to 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


DECLARATION AND UNDERTAKING

APPEAL OR APPLICATION NUMBER:
I hereby declare that
  1. I am
    1. in the case of a counsel, a member of the Bar of ; or
    1. in the case of an expert who assists the counsel, a person possessing expertise in ; or
  1. I am ordinarily resident in Canada;
  1. I am not an employee, officer, director or major shareholder of any party to the proceedings or of any related persons1; and


1Section 2 of the Hazardous Materials Information Review Act Appeal Board Procedures Regulations provides as follows:

" "related group" means a group of persons each member of which is a related person with respect to every other member of the group;
"related persons" means persons who are:
(a) individuals connected by a blood relationship, marriage or adoption or
(b) a corporation and

    (i) the person who controls the corporation, if it is controlled by one person,
    (ii) a person who is a member of a related group that controls the corporation, or
    (iii) any person who is a related person describing in subparagraph (i) or (ii)."



  1. I am not an employee, official or a representative of a union association
I hereby undertake that
  1. I will not disclose any confidential information that I obtain in the course or as a consequence of those 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;
  1. 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
  1. 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
    1. the 30th day after the decision of the appeal board, and
    1. the expiration of any period form 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 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.
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

  1. 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
  2. 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."