Form Builder

Required fields are marked with asterisks (*)

Appeal Withdrawal

Purpose

Complete this form to withdrawal your appeal. A withdrawal ends the appeal process. When you withdraw your appeal, you will no longer have a hearing and the Business Licensing Decision Notice or Property Standards Order issued to you is in effect

NOTE: There is no refund of the fees for the Appeal Request.

Notice of Collection

Personal information in this form is collected under the authority of the applicable City of Burlington's Licensing By-Laws and the Property Standards By-Law, and will be used to process applications for an appeal. Information, including completed forms, you provide to the Burlington Appeals Committee forms part an adjudicative record that is a public record available to parties, participants and the general public. Under Section 27 of the Municipal Freedom of Information and Protection of Privacy Act, the provisions protecting individual privacy in Part 2 of the Act do not apply to this information. Questions about this collection should be directed to the City Clerk Legislative Services, E:clerks@burlington.ca P: 905-335-7777.

The withdrawal is for:

Business Licence Decision Notice

Property Standards Order

Name of Appellant

Address:

Unit:

City:

Province:

Postal code:

Primary phone number:

Email address:

Business Licence Decision Notice Number/Property Standards Order Number

Withdrawal the appeal scheduled for a hearing on: (date mm/dd/yyyy)

Briefly explain your reason for withdrawing your appeal:

Appellant/Authorized Agent signature:

Clear