Request for Insertion Form — Non-federal Government Clients

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 government departments and agencies.

Sections 1, 2 and 3 are mandatory.

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

Requesting Organization’s Name ____________________________________________

Address _______________________________________________________________

Contact Name  __________________________________________________________

Telephone and Extension Nos. _____________________________________________

Email __________________________________________________________________

SECTION 2 — NOTICES

Title of Document Submitted _______________________________________________

Date Submitted __________________________________________________________

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

______________________________________________________________________

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 CONTACT INFORMATION

Organization’s Name _____________________________________________________

Address _______________________________________________________________

Contact Name __________________________________________________________

Telephone and Extension Nos. ___________________

Email _________________________

Business Number (Mandatory) _____________________________________________

Do you need?

checkbox Legal Affidavit ($22)

checkbox Translation *

* Notices published under the Navigable Waters Protection Act only 

How many times must your notice be published?

checkbox Once                                        checkbox Four times

Signature ____________________         Date _____________________

SECTION 4 — FOR USE BY THE CANADA GAZETTE DIRECTORATE

Date of Publication ________________

Issue Number ____________________

Number of Pages __________________

Customer Number _________________

SIGMA Invoice Number ______________

Cost ____________________________