Transportation Appeal Tribunal of Canada Certificate Regulations (SOR/2004-130)

In the matter of the contravention of (specify designated provision) by (identify contravener)

It is hereby certified that, at the conclusion of the proceedings held before this Tribunal on (specify date), I assessed the amount of $(specify amount) to be paid by (identify contravener) on or before (specify date) as a penalty in respect of the contravention of (specify designated provision), which occurred on (specify date).

Dated this day of , 20

Signed by: Name of Tribunal Member

Address of Tribunal