Form 91.05(A)

                                                                                                            C.A. No.

Nova Scotia Court of Appeal

Between:

            [name]                                                                                    Appellant

and

            [name]                                                                                    Respondent

Notice of Appeal

(Where appellant is represented by a solicitor)

To:      [name of respondent]

PARTICULARS OF CONVICTION:

1. Place of conviction                                                                                                                         

2. Name of Judge                                                                                                                                

3. Name of Court                                                                                                                                

4. Name of Crown Prosecutor at trial                                                                                                 

5. Name of Defence Counsel at trial                                                                                                  

6. Offence(s) charged:__________________________ under __________________ (state sections of Criminal Code or other statute)

7. Offence(s) of which appellant convicted                                                                                        

8. Sections of the Criminal Code or other statutes under which appellant convicted  

9. Plea at trial                                                                                                                                      

10. Sentence imposed                                                                                                                         

11. Date of conviction                                                                                                                        

12. Date of sentence                                                                                                                           

13. If appellant in custody, place of incarceration                                                                              

Take notice that the appellant: (insert whichever of the following is applicable)

(1) appeals against his conviction upon grounds involving a question of law alone;

(2) applies for leave to appeal his conviction upon grounds involving a question of fact alone or a question of mixed law and fact, and if leave be granted hereby appeals against the said conviction;

(3) applies for leave to appeal against sentence, and if leave be granted hereby appeals against the sentence.

Grounds of appeal and relief sought

This appeal is brought under section              of the [Criminal Code/other]  .

The grounds of appeal are as follows:

1          [state grounds concisely]

2

3                                                                                                                      .

At the conclusion of the appeal the appellant will request an order that [concisely describe order sought] .

Contact information

The appellant designates the following address:

Documents delivered to this address are considered received by the appellant on delivery.

Further contact information is available from the registrar.

Signature

Signed                                    , 20

                                                                                                Signature of Appellant

                                                                                    Print name:

                                                                                    [or]

                                                                                                Signature of counsel

                                                                                    [name] as counsel

                                                                                    for [name of appellant]

Registrar’s certificate

I certify that this notice of appeal was filed with the Court of Appeal on                              , 20 .

Registrar