REQUEST FOR INSERTION FORM
NON-FEDERAL GOVERNMENT CLIENTS

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

Requesting organization’s name ____________________________________________

Address _______________________________________________________________

Contact name  __________________________________________________________

Telephone and extension numbers ___________________________________________

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

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

Organization’s name _____________________________________________________

Address _______________________________________________________________

Contact name __________________________________________________________

Telephone and extension numbers ___________________

Email _________________________

Do you need?

Legal Affidavit ($22)

Translation *

* Notices published under the Navigable Waters Protection Act only 

How many times must your notice be published?

Once                                         Four times

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

Yes                                           No

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 ____________________________