Form A 103 – Fill Out and Use This PDF

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File N o . ____________

EM PLOYM EN T STAN D ARD S ACT, 2 0 0 0

APPLI CATI ON FOR REV I EW

Please com plet e t his form , set t ing out t he fact s and reasons support ing your request . Deliver t he applicat ion and ot her docum ent s t o t he ot her workplace part y( ies) and t o t he Direct or of Em ploym ent St andards. Then file t he signed original, as well as t he support ing docum ent s, wit h:

Th e Re gist r a r

On t a r io La bou r Re la t ion s Boa r d

5 0 5 Un iv e r sit y Av e n u e , 2 n d Floor Tor on t o, On t a r io M 5 G 2 P1

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PART I : N ATURE OF TH E APPLI CATI ON

Please indicat e which Se ct ion of t he Em ploy m ent St andar ds Act , 2000 applies t o your applicat ion for review .

[] Se ct ion 1 1 6 ( 1 ) ( b) or ( c) Are you an EM PLOYER, TEM PORARY H ELP AGEN CY or CLI EN T OF A TEM PORARY H ELP AGEN CY who wishes t o obj ect t o an Order m ade by an Em ploym ent St andards Officer?

YOUR APPLI CATI ON MUST BE FI LED WI TH THE BOARD

WI THI N 3 0 CALEN D AR D AYS AFTER THE DAY ON WHI CH

THE ORDER WAS SERVED. I N THE CASE OF AN ORDER

UNDER SECTI ON 74.14 OR 103, YOU MUST PAY THE FULL

AMOUNT ORDERED TO THE DI RECTOR OF EMPLOYMENT

STANDARDS ( WHO WI LL HOLD THE MONEY I N TRUST) OR

PROVI DE AN I RREVOCABLE LETTER OF CREDI T ACCEPTABLE

TO THE DI RECTOR. I N THE CASE OF AN ORDER UNDER

SECTI ON 74.16, 74.17 OR 104, YOU MUST PAY THE AMOUNT

ORDERED OR $10,000 ( WHI CHEVER I S LESS) TO THE

DI RECTOR OF EMPLOYMENT STANDARDS ( WHO WI LL HOLD

THE MONEY I N TRUST) OR PROVI DE AN I RREVOCABLE

LETTER OF CREDI T ACCEPTABLE TO THE DI RECTOR.

You r a pp lica t ion w ill n ot be p r oce sse d w it h ou t a copy of y ou r pr oof of pa y m e n t t o t h e D ir e ct or of Em ploy m e n t St a n da r d s.

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[	] Se ct ion 1 1 6 ( 2 )		Are you an EM PLOYEE who wishes t o obj ect t o an Order
	1 1 6 ( 3 )		m ade by an Em ploym ent St andards Officer or t o t he
			refusal t o issue an Order?
			YOUR APPLI CATI ON MUST BE FI LED WI TH						THE	BOARD
			WI THI N 3 0 CALEN D AR D AYS AFTER THE DAY ON WHI CH
			THE ORDER, LETTER ADVI SI NG OF THE ORDER						OR	LETTER
			ADVI SI NG OF THE REFUSAL TO I SSUE AN					ORDER		I S
			SERVED OR WI THI N 3 0 CALEN D AR D AYS AFTER THE DAY
			ON WHI CH A LETTER OF REFUSAL I S DEEMED TO HAVE
			BEEN SERVED.
[	] Se ct ion 1 1 6 ( 1 ) ( a ) Are you a com pany D I RECTOR who wishes t o obj ect t o
		an Order m ade against you personally, as a DI RECTOR, under
		s. 106 or 107 by an Em ploym ent St andards						Officer? [ PLEASE
		NOTE:		I f you	are obj ect ing t o		an Order	m ade against an
		EMPLOYER, you MUST com ply wit h t he direct ions above under
		s. 116( 1) for “ EMPLOYER” .]
		YOUR APPLI CATI ON MUST BE					FI LED WI TH		THE	BOARD
		WI THI N 3 0 CALEN D AR D AYS AFTER THE DAY ON WHI CH THE
		ORDER WAS SERVED.
[	] Se ct ion 1 2 2 Are you			a PERSON		AGAI N ST W H OM		A	N OTI CE OF
		CON TRAV EN TI ON H AS BEEN I SSUED who wishes t o disput e
		t he Not ice?
		YOUR APPLI CATI ON MUST BE					FI LED WI TH		THE	BOARD
		WI THI N 3 0 CALEN D AR D AYS AFTER THE DATE OF SERVI CE
		OF THE NOTI CE.
PART I I :		TH E APPLI CAN T( S) ( t h is se ct ion is for in f or m a t ion a bou t you )
W h e r e t h e r e a r e			m u lt ip le a p p lica n t s,			p le a se	a t t a ch a	se p a r a t e		sh e e t
p r ov id in g		n a m e s,	a d d r e sse s,		t e le p h on e / fa x		n u m b e r s		a n d	e - m a il
a d d r e sse s for e a ch a p p lica n t .

PLEASE N OTI FY TH E ON TARI O LABOUR RELATI ON S BOARD I M M ED I ATELY OF AN Y CH AN GE I N YOUR AD D RESS, PH ON E OR FAX N U M BERS, OR YOU R E- M AI L AD D RESS. I F YOU FAI L TO N OTI FY TH E BOARD OF AN Y CH AN GES, CORRESPON D EN CE SEN T TO YOUR LAST KN OW N AD D RESS M AY BE D EEM ED TO BE REASON ABLE N OTI CE TO YOU AN D TH E APPLI CATI ON M AY PROCEED I N YOUR ABSEN CE.

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N a m e :

Ad dr e ss:

Te le ph on e :

Fa x :

E- m a il:

N a m e of Re pr e se n t a t iv e ( if any) :

Addr e ss:

Te le ph on e :

Fa x :

E- m a il a d d r e ss of r e pr e se n t a t iv e a n d a ssist a n t ( if a n y ) :

□	Cou n se l:	Assist a n t :
□	Pa r a le g a l:	Assist a n t :
□	ot h e r :	Assist a n t :

PART I I I : ( this section is for inform ation about the other w orkplace party( ies) )

A. I f y ou a r e a n Em ploy e r , Te m por a r y H e lp Age n cy or Clie n t of a Te m por a r y H e lp Age n cy , pr ov ide in f or m a t ion on t h e Em p loy e e ( s) :

N a m e :

Ad dr e ss:

Te le ph on e :Fa x :

E- m a il a ddr e ss:

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N a m e of Re pr e se n t a t iv e ( if any) :

Ad dr e ss:

Te le ph on e :

Fa x :

E- m a il a d d r e ss of r e pr e se n t a t iv e a n d a ssist a n t ( if a n y ) :

□	Cou n se l:	Assist a n t :
□	Pa r a le ga l:	Assist a n t :
□	ot h e r :	Assist a n t :
B.	I f y ou a r e a n Em ploy e e , pr ov id e	in for m a t ion on t h e Em ploy e r ( s) ,
	Te m p or a r y H e lp Age n cy or Clie n t of t h e Te m p or a r y H e lp Ag e n cy :

N a m e :

Ad dr e ss:

Te le ph on e :	Fa x :
E- m a il a ddr e ss:

N a m e of Re pr e se n t a t iv e ( if any) :

Ad dr e ss:

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Te le ph on e :

Fa x :

E- m a il a d d r e ss of r e pr e se n t a t iv e a n d a ssist a n t ( if a n y ) :

□	Cou n se l:	Assist a n t :
□	Pa r a le ga l:	Assist a n t :
□	ot h e r :	Assist a n t :
C.	I f y ou a r e a	Com pa n y D ir e ct or , p r ov ide in for m a t ion on t h e

Em ploy e r ( s) , t h e Em ploy e e ( s) a n d a ll ot h e r D ir e ct or s.

( Wher e t her e ar e m ult iple com pany dir ect or s, em ploy er s, or em ploy ees, please at t ach a separ at e sheet pr ov iding nam es, addr esses, t elephone/ fax num ber s and e- m ail addr esses for each dir ect or , em ploy er and em ploy ee. )

N a m e :

Ad dr e ss:

Te le ph on e :	Fa x :
E- m a il a ddr e ss:

N a m e of Re pr e se n t a t iv e ( if any) :

Ad dr e ss:

Te le ph on e :

Fa x :

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E- m a il a d d r e ss of r e pr e se n t a t iv e a n d a ssist a n t ( if a n y ) :

□	Cou n se l:	Assist a n t :
□	Pa r a le ga l:	Assist a n t :
□	ot h e r :	Assist a n t :

PART I V : TH E ORD ER or N OTI CE

Your Applicat ion includes ( as applicable) :

[ ] a copy of t he em ploym ent st andards officer’s narrat ive report

[] a copy of t he Order

[ ] a copy of t he let t er advising t he em ployee of t he Order

[] a copy of t he let t er advising of t he refusal t o issue an Order, or

[] a copy of t he Not ice of Cont ravent ion

[ ] a copy of proof of paym ent t o t he Direct or of Em ploym ent St andards or an explanat ion w hy t he relevant docum ent is not included.

ES File N u m b e r :

Or de r / N ot ice N u m b e r :

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PART V : TH E REASON S FOR YOUR APPLI CATI ON

Your applicat ion should include a general st at em ent of what you are seeking and why . I nclude a concise st at em ent of t he fact s and event s upon which you rely t o support your posit ion. The quest ion for t he Board is whet her t here has been a breach of t he Em ploym ent St andards Act , 2000 and if so, what t he appropriat e order should be.

You m ay at t ach addit ional pages if necessary .

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TI M ELI N ESS

You r a p p lica t ion w ill n ot b e p r oce sse d if t h is se ct ion h a s n ot b e e n com p le t e d .

D a t e of Se r v ice of Or d e r / N ot ice or Le t t e r ( as applicable) :

	[	]		is
Th is a p p lica t ion f or r e v ie w	[	]	is n ot		be in g file d w it h in 3 0 ca le n da r
da y s a ft e r t h e d a y on w h ich		t h e		Or de r ,	N ot ice , Le t t e r a dv isin g of t h e

Or de r , or Le t t e r a dv isin g of t h e r e f u sa l t o issu e a n Or de r , a s t h e ca se m a y be , w a s se r v e d .

I f you want t he Board t o consider t his applicat ion ev en t hough it has been filed aft er t he 30 - day t im e lim it , you should set out , in det ail, all of your reasons why an ext ension of t im e should be grant ed by t he Board. You m ay at t ach addit ional pages if necessary .

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

PROOF OF PAYM EN T

Com p le t e t h is se ct ion on ly if y ou a r e a n e m p loy e r , t e m p or a r y h e lp a g e n cy or clie n t of a t e m p or a r y h e lp a ge n cy a p p ly in g for r e v ie w u n d e r se ct ion 1 1 6 ( 1 ) of t h e Act .

[] I cert ify t hat I have paid t he am ount owing under t he order ( or $10,000, as applicable) t o t he Direct or of Em ploym ent St andards in t rust or provided t he

Direct or wit h an irrevocable let t er of credit accept able t o t he Direct or in t hat am ount . A copy of proof of paym ent is at t ached.

This applicat ion consist s of _______ pages in t ot al.

D a t e _____________

____________________

Sig n a t u r e

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CERTI FI CATE OF D ELI V ERY

You m u st d e liv e r t h is a pplica t ion t o t h e D ir e ct or of Em ploy m e n t St a n da r ds a n d a ll t h e ot h e r w or k pla ce p a r t ie s, a n d file y ou r a pplica t ion w it h t h e Boa r d w it h in fiv e ( 5 ) d a y s of de liv e r in g it t o t h e m .

1.	I cert ify t hat t he following docum ent s were delivered t o [ ] t he Direct or of
	Em ploym ent St andards, as follows:

•Applicat ion for Review ( and support ing docum ent s, including full

paym ent of t he order, or $10,000, as applicable, if you are t he em ployer) under t he Em ploy m ent St andar ds Act , 2000

FOR DELI VERY TO THE DI RECTOR OF EMPLOYMENT STANDARDS, PLEASE SEND YOUR COMPLETED APPLI CATI ON AND ATTACHED DOCUMENTS:

BY EM AI L: appforreview .direct orofES@ont ario.ca

BY TOLL FREE FAX : 1 855 251- 5025

BY REGULAR M AI L OR H AN D D ELI V ERY:

	Direct or of Em ploym ent St andards
	Em ploym ent Pract ice Branch
	Minist ry of Labour
	400 Universit y Avenue, 9t h Floor
	Toront o, ON
	M7A 1T7
2.	I cert ify t hat t he following docum ent s were delivered t o t he ot her workplace
	part ies: [ ] em ployer( s) , [ ] em ployee( s) , [ ] t em porary help agency, [
	] client of a t em por ary help agency, or [ ] com pany direct or( s) as follows
	( add m ore pages, as necessary) :

•	Applicat ion for Review ( and support ing docum ent s) under t he
•	Em ploy m ent St andar ds Act , 2000 ;
	I nform at ion Bullet in No. 24 – “ Applicat ion for Review under
	t he Em ploym ent St andards Act , 2000

____________________________	____________________________________
Nam e and Tit le	Address or facsim ile num ber t o which
	docum ent s were delivered

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____________________________	____________________________________
Nam e and Tit le	Address or facsim ile num ber t o
	which docum ent s w ere delivered

____________________________	____________________________________
Nam e and Tit le	Address or facsim ile num ber t o which
	docum ent s were delivered

[ Com ple t e e it h e r se ct ion 3 or se ct ion 4 or se ct ion 5 b e low . ]

3.	These docum ent s were delivered by [ ] facsim ile t ransm ission or
	[ ] hand delivery on __________________ at _________ a.m ./ p.m .
	( Dat e)
4.	These docum ent s were sent by [ ] regular m ail on
	____________________ at ________ a.m . / p. m .
	( Dat e)
5.	These docum ent s were given t o ___________________________ on

( Nam e of Courier)

__________________, and I was advised t hat t hey would be delivered

( Dat e)

not lat er t han ___________________, at __________ a.m . / p.m .

( Dat e)

NAME: _______________________

TI TLE: ________________________

SI GNATURE: _______________________

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I M PORTAN T N OTES

FREN CH OR EN GLI SH

Si vous com m uniquez avec la Com m ission, vous avez le droit de recevoir des services en français et en anglais. Vous pouvez consult er les règles de la Com m ission, les form ulaires et les bullet ins d’inform at ion sur le sit e Web de la Com m ission au www .olrb.gov .on. ca ou com poser le 416- 326- 7500 ou

( sans frais) le 1 877	339- 3335	pour de plus	am ples	renseignem ent s.
Veuillez prendre not e	que la	Com m ission	n’offre	pas de services

d’int erprét at ion dans les langues aut res que le français et l’anglais.

You have t he right t o com m unicat e wit h, and receive available services from , t he Board in eit her English or French. You can access t he Board’s Rules,

Form s and	I nform at ion Bullet ins from it s websit e at www .olrb.gov .on.ca or
by calling	416- 326- 7500.	Please not e t hat t he Board does not provide

t ranslat ion services in languages ot her t han English or French.

CH AN GE OF AD D RESS

Please not ify t he Board im m ediat ely of any change in your address, phone or fax num bers, or your e- m ail address. I f you fail t o not ify t he Board of any changes, correspondence sent t o your last known address m ay be deem ed t o be reasonable not ice t o you and t he applicat ion m ay proceed in your absence.

EM AI L

I f you have provided an e- m ail address wit h your cont act inform at ion, t he Board will in all likelihood com m unicat e wit h you by e- m ail from a generic out - going address. Please be advised t hat t he Board is not yet equipped t o receive com m unicat ions from you by e- m ail.

OLRB RULES OF PROCED URE

The Board’s Rules of Procedure describe how an applicat ion, response or int ervent ion m ust be filed, what inform at ion m ust be provided and t he t im e lim it s t hat apply . You can obt ain a copy of t he Rules from t he Board’s office at 505 Universit y Avenue, 2nd Floor, Toront o, Ont ario, M5G 2P1 ( Tel: 416- 326- 7500) or from t he Board’s websit e.

ACCESSI BI LI TY a n d ACCOM M OD ATI ON

I n accordance wit h t he Accessibilit y for Ont ar ians w it h Disabilit ies Act , 2005,

t he Board m akes every	effort	t o ensure t hat it s services are provided in a
m anner t hat respect s	t he	dignit y and independence of persons wit h

disabilit ies. Please t ell t he Board if you require any accom m odat ion t o m eet your individual needs.

FREED OM OF I N FORM ATI ON a n d PROTECTI ON OF PRI V ACY

Personal inform at ion is collect ed on t his form under t he aut horit y of t he Board’s governing legislat ion t o assist in t he processing of t his applicat ion. I n addit ion, inform at ion received in writ t en or oral subm issions m ay be used

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and disclosed for t he proper adm inist rat ion of t he Board’s legislat ion and processes. The Fr eedom of I nfor m at ion and Pr ot ect ion of Pr iv acy Act , R.S.O. 1990 F.31 governs t he collect ion, use and disclosure of t his inform at ion.

Any inform at ion t hat you provide t o t he Board t hat is relevant t o t his applicat ion m ust in t he norm al course be provided t o t he ot her part ies t o t he proceeding.

H EARI N GS a n d D ECI SI ON S

Board hearings are open t o t he public unless t he panel decides t hat m at t ers involving public securit y m ay be disclosed or if it believes t hat disclosure of financial or personal m at t ers would be dam aging t o any of t he part ies. Hearings are not recorded and no t ranscript s are produced.

The Board issues writ t en decisions, which m ay include t he nam e and personal inform at ion about persons appearing before it . Decisions are available t o t he public from a variet y of sources including t he Ont ario Workplace Tribunals Library, and over t he int ernet at www .canlii.org, a free legal inform at ion dat a base. Som e sum m aries and decisions m ay be found on t he Board’s websit e under Highlight s and Recent Decisions of I nt erest .

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