REQUEST FOR INSERTION FORM — 
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 _______________________________________________________

Part Ⅰ

Part Ⅱ

Requesting organization’s name __________________________________________

Address _____________________________________________________________

Contact name ________________________________________________________

Telephone number ____________________________________________________

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

Part Ⅰ

Part Ⅱ

Number of copies (minimum of 100) _______________________________________

Date of publication expected _____________________________________________

Text provided

English

Original

Copy

French

Original

Copy

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 number ____________________________________________________

Email _______________________________________________________________

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

Yes

No

Estimated cost _______________________________________________________

Note

If you publish a notice in the Canada Gazette, Part Ⅰ, a free copy will be sent to the address indicated in Section 3.

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  _______________________________________________________________