Attention: General Manager

I am aggrieved or dissatisfied by an:

Enter an ORDER #, DECISION or DETERMINATION in this field

of the:

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dated:

Enter date of the ORDER, DECISION or DETERMINATION in this field

because:

Provide a brief explanation of reason(s) for appeal. Include why the decision should be changed and state the outcome (BCFIRB decision ) requested.

Attached is my cheque in the amount of $100.00 made payable to the Minister of Finance. I understand the filing fee is non-refundable.

My name and mailing address is:

Name Address Address City, British Columbia Postal Code

My location (civic address) for delivery of any notices related to the appeal, if different from mailing address:

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My telephone number, fax, e-mail [if available] are:

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Telephone

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Fax number

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E-mail

Agent information (optional):

Name and address of agent working on my behalf:Name Address Address City, British Columbia Postal Code

Telephone number, fax, e-mail [if available] of agent working on my behalf:

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Telephone
 

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Fax number
 

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E-mail