Request for insertion form — Federal Departments and Agencies

Note: If your notice is to be published after March 31, 2014, please complete the updated version of the request for insertion form for federal departments and agencies.

Sections 1, 2 and 3 are mandatory. Missing information might delay the publication of your notice.

To

Canada Gazette Directorate
Public Works and Government Services Canada
350 Albert Street, 5th Floor
Ottawa, Ontario K1A 0S5

Telephone: 1-866-429-3885
Web site: www.gazette.gc.ca

SECTION 1 — CLIENT INFORMATION

Date submitted _______________________________________________________

checkbox Part Ⅰ

checkbox Part Ⅱ

checkbox Department/Agency

checkbox Crown corporation

Requesting organization’s name __________________________________________

Address _____________________________________________________________

Contact name _________________________________________________________

Telephone and extension numbers _________________________________________

Email ________________________________________________________________

Consignee code _______________________________________________________

Department number ___________________________________________________

IS organization code ___________________________________________________

IS reference code _____________________________________________________

SECTION 2 — NOTICES

Title of document submitted _______________________________________________

Published under the authority of (section of Act, Regulations, etc.)

____________________________________________________________________

If you wish hot links to appear in the electronic versions of your notice, please give us specific instructions.

____________________________________________________________________

Extracts

checkbox Part Ⅰ

checkbox Part Ⅱ

Number of copies (minimum of 100) _______________________________________

Date of publication expected _____________________________________________

Note

If you have not received a call from us confirming receipt of your notice and its publication date by Monday, 12 p.m. [Eastern standard time] of the week of the expected publication date, please contact us.

SECTION 3 — INVOICING

The invoice will be sent to the contact and email address indicated below.

Organization’s name ___________________________________________________

Address _____________________________________________________________

Contact name ________________________________________________________

Telephone and extension numbers _________________________________________

Email _______________________________________________________________

Are you submitting a USB key, a CD-ROM or a diskette with your text?

checkbox Yes

checkbox No

Estimated cost _______________________________________________________

If required - Pursuant to section 32 of the Financial Administration Act, funds are available.

Signature  ________________________________________________________

Date  ____________________________________________________________

SECTION 4 — FOR USE BY THE CANADA GAZETTE DIRECTORATE

Date of publication ____________________________________________________

Issue number ________________________________________________________

Number of pages ______________________________________________________

SIGMA invoice number __________________________________________________

Cost  _______________________________________________________________