Application to an appeals officer

The HTML version of this application form is presented as an example only. To fill out and print an Application to Appeal please use the PDF Version.

Occupational Health and Safety Tribunal Canada

Tribunal de santé et sécurité au travail Canada

Arms of Canada

Ottawa, Canada K1A 0J2

Application to an appeals officer

Case number:

The appeal

Name of the appellant:

Name of organization representing the appellant (if applicable):

Name and title of the appellant’s representative (if applicable):

Name of the respondent (if applicable):

Name of organization representing the respondent (if applicable):

Name and title of the respondent’s representative (if applicable):

The application and grounds

Attach additional pages if necessary.

Application by:

Appellant

[yes/no]

Respondent

[yes/no]

Explain the nature of the application:

Explain how the appellant would likely suffer significant harm if the appeals officer did not grant the stay. Attach any documents needed to support your explanation:

Explain why the appeals officer should grant the application:

Signature of applicant:

Date:

Name of signatory:

Total number of pages submitted:

Please include a copy of the decision(s) or direction(s) if available

200-47 Clarence Street, Ottawa ON  K1A 0J2
Email: registrar-registraire@ohstc-tsstc.gc.ca
Occupational Health and Safety Tribunal Canada
Telephone number: 613-437-0612 or 1-866-440-3343 / Facsimile number: 613-437-0600

Symbol of the Government of Canada

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