Government of Ontario

Tribunals Ontario
Animal Care Review Board

Declaration of Representative

Important Information

If you have a representative for a matter before the Board, have them fill in this form clearly and completely and provide it to the Board and all other parties immediately.
You must notify the Board and all parties in writing if the representative you name stops representing you and you find a new representative, or you decide to represent yourself.
Only persons licenced by the Law Society of Ontario (LSO) or who fall within the exceptions or exemptions approved by the LSO may represent a party before the Tribunal.
For the current list of exemptions for unlicensed representatives, visit the LSO website at www.lso.ca.

1. Representative Information

Last Name
First Name
Middle Initial

Company Name

Address
Unit Number
Street Number
Street Name
PO Box
City/Town/Municipality
Province
Postal Code

Telephone Number
Fax Number
Email Address

2. Declaration of Representative

I am representing (Name of Party)

Before the Animal Care Review Board in the matter of (Name of Appellant) Last Name
First Name
Middle Initial

And (Name of Respondent)
Last Name
First Name
Middle Initial

3. Acknowledgement

I acknowledge that I am licensed by the Law Society of Ontario (LSO) to provide legal services.
My LSO No. is

I acknowledge I am an unlicensed representative covered by an exemption allowed by the LSUC.

Name of Representative

Signature of Representative

Date (yyyy/mm/dd)

The Animal Care Review Board (ACRB) collects the personal information requested on this form under section 38 of the Provincial Animal Welfare Services Act and section 9(5) of Ontario Regulation 443/19 for the purpose of conducting an appeal proceeding before the ACRB. All information, including sensitive personal and financial information, submitted as part of a proceeding may become public in an open hearing and may be contained in decisions, orders, and case files, unless an order to restrict access is made. Any questions about the collection of information may be directed to the ACRB at ACRB.registrar@ontario.ca.

If you have any questions, please contact

Animal Care Review Board
15 Grosvenor St, Ground Fl
Toronto ON M7A 2G6
Telephone: 416-327-0111 / 1-888-777-3616
Teletypewriter (TTY): 1-800-855-0511
Fax: 416-314-4270 / 1-800-720-5292
Website: tribunalsontario.ca/acrb
Email: ACRB.registrar@ontario.ca

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