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
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
