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 number _______________________________________________________

Email __________________________________________________________________

SECTION 2 — NOTICES

Title of document submitted _______________________________________________

Date submitted __________________________________________________________

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

______________________________________________________________________

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 _________________________

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 CD-ROM or diskette with your text?

Yes                                           No

Note

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

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 ____________________________