Hazardous Materials Information Review Commission - Government of Canada

Hazardous Materials
Information Review Act Appeal
Board Procedures Regulations

FORM 2
[Subsection 5(1)]
APPEAL NUMBER


APPEAL BOARD
HAZARDOUS MATERIALS INFORMATION REVIEW ACT

IN THE MATTER OF:

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



APPLICATION

PART I - GENERAL INFORMATION

NAME OF APPLICANT:

ADDRESS:

CITY:

PROVINCE:

POSTAL CODE:

ADDRESS FOR SERVICE:
(if different from above)

CONTACT PERSON:
(where applicant is a Corporation)

TITLE:

ADDRESS FOR SERVICE:

TELEPHONE:

OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:

COUNSEL (if any):

FIRM:

ADDRESS FOR SERVICE:

TELEPHONE:

OTHER MEANS OF TELECOMMUNICATIONS AND THEIR NUMBERS:

LANGUAGE OF PREFERENCE:
ENGLISH FRENCH


PART II - STATUS (Section 20 of the Act and subsection 2(2) of the Hazardous Materials Information Review Regulations)

NOTE: This Part seeks information in respect of the status of the person filing the application. 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 present application, the applicant is

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
  1. a supplier of the controlled product
  1. an employer at the work place
  1. 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


PART III - INFORMATION REGARDING CLAIMANT

Provide the name and address of the employer or supplier that has the confidential business information that is the subject of the application.

Where the employer or supplier carries on business in one province, name the province:


Where the employer or supplier carries on business in more than one province, name the province most directly concerned with the application and explain why the province is the province that is most directly concerned with the application:
PROVINCE:
EXPLANATION:


PART IV - ORDER SOUGHT

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 to be made.



PART V - REPRESENTATIONS

NOTE: Section 26 of the Act permits an appeal board to make an order for disclosure, in confidence, of confidential business information to named affected parties or each member of a class of affected parties. The order may be made for reasons of health and safety in a work place.

Provide a full statement of the reasons, facts and circumstances supporting the application. Attach additional sheets if necessary.



PART VI - CONFIDENTIAL INFORMATION

NOTE: The applicant may place confidential information in this separate part of the application and shall mark each sheet of confidential information with the word "Confidential/Confidential".

CONFIDENTIAL/CONFIDENTIEL:



PART VII - DECLARATION

I, , hereby certify on behalf of the appellant herein that the information in Parts I to VI of this Form is true to the best of my knowledge and belief.



(Signature)

(Date)

(Title)