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APPEAL/OBJECTION FORM (A2) - Ontario Municipal Board

APPEAL/OBJECTION FORM (A2) - Ontario Municipal Board

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Part 2: Location Information<br />

________________________________________________________________________________________________<br />

Address and/or Legal Description of property subject to the appeal:<br />

<strong>Municipal</strong>ity:<br />

___________________________________________________________________________________<br />

Part 3: Appellant Information<br />

First Name: ________________________________________Last Name: _______________________________________________<br />

___________________________________________________________________________________________________________<br />

Company Name or Association Name (Association must be incorporated – include copy of letter of incorporation)<br />

Professional Title (if applicable): _________________________________________________________________________________<br />

E-mail Address: ______________________________________________________________________________________________<br />

By providing an e-mail address you agree to receive communications from the OMB by e-mail.<br />

Daytime Telephone #:________________________________ Alternate Telephone #: ______________________________________<br />

Fax #:_____________________________________________<br />

Mailing Address: _____________________________________________________________________________________________<br />

Street Address Apt/Suite/Unit# City/Town<br />

____________________________________________________________________________________________<br />

Province Country (if not Canada) Postal Code<br />

Signature of Appellant: _____________________________________________________________Date:_______________________<br />

Please note: You must notify the <strong>Ontario</strong> <strong>Municipal</strong> <strong>Board</strong> of any change of address or telephone number in writing. Please<br />

quote your OMB Reference Number(s) after they have been assigned.<br />

Personal information requested on this form is collected under the provisions of the Development Charges Act, 1997, S.O. 1997, c.<br />

27, as amended, the Education Act, R.S.O., 1990, c.E.2, as amended, and the <strong>Ontario</strong> <strong>Municipal</strong> <strong>Board</strong> Act, R.S.O. 1990, c. O. 28 as<br />

amended. After an appeal is filed, all information relating to this appeal may become available to the public.<br />

Part 4: Representative Information (if applicable)<br />

I hereby authorize the named company and/or individual(s) to represent me:<br />

First Name: ________________________________________Last Name: _______________________________________________<br />

Company Name: _____________________________________________________________________________________________<br />

Professional Title: ____________________________________________________________________________________________<br />

E-mail Address: ______________________________________________________________________________________________<br />

By providing an e-mail address you agree to receive communications from the OMB by e-mail.<br />

Daytime Telephone #:________________________________ Alternate Telephone #: ______________________________________<br />

Fax #:_____________________________________________<br />

Mailing Address: _____________________________________________________________________________________________<br />

Street Address Apt/Suite/Unit# City/Town<br />

____________________________________________________________________________________________<br />

Province Country (if not Canada) Postal Code<br />

Signature of Appellant: _____________________________________________________________Date:______________________<br />

(see over)<br />

<strong>A2</strong> Rev. 01/23/2007 Page 2 of 4

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