Form 1A NOTICE OF APPEAL OR APPLICATION

FOR LEAVE TO APPEAL Summary Conviction Appeal

Criminal Code Subsection 839(1)

Lower Court Registry Number: .........................................

Lower Court Registry Location: ........................................

COURT OF APPEAL

REGINA Respondent

vs.

........................................... Appellant

PARTICULARS OF DECISION ON APPEAL

1 Place of conviction ............................................................................................

Place of appeal to Supreme Court.....................................................................

2 Name of Judge – Trial (Provincial Court) ..........................................................

– Appeal Court (Supreme Court)..............................................

3 Offence(s) of which the appellant was convicted at trial and with respect to

which the appellant's appeal to the Supreme Court was dismissed

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4 Section(s) of Criminal Code or other Act under which the appellant was

convicted............................................................................................................

5 Plea at trial…......................................................................................................

6 Length of trial .....................................................................................................

Length of appeal proceedings in Supreme Court ..............................................

7 Sentence imposed — Trial …….........................................................................

Sentence on appeal (if different) …....................................................................

8 Date of conviction at trial ...................................................................................

Date of Supreme Court decision .......................................................................

9 Date of sentence ...............................................................................................

10 If appellant in custody, place of incarceration ……............................................

TAKE NOTICE that the appellant applies for leave to appeal the decision dismissing the summary conviction appeal on grounds involving a question of law alone, and if leave be granted, hereby appeals against the said decision.

The grounds of appeal are............................................................................................

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(Use additional separate sheet if necessary)

The relief sought is....................................................................................

The appellant's address for service is.......................................................................

Dated this ......... day of .........................., 20.......

...................................................... Solicitor on behalf of appellant

To the Registrar