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.
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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.......
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Solicitor on behalf of appellant
To the Registrar