Rules of the Supreme Court of Canada

TAKE NOTICE that (name) hereby applies for leave to appeal to the Court, pursuant to (cite the section of the Act or these Rules under which the application for leave is made), from the judgment of the (name of the court appealed fromand file number from that court) made (date), and for (insert the nature of order or relief sought) or any further or other order that the Court may deem appropriate;

AND FURTHER TAKE NOTICE that this application for leave is made on the following grounds: (set out concisely and number each ground on which the application is made).

Dated at (place and province or territory) this (date) day of (month), (year).

SIGNED BY (signature of counsel or party or agent)

Applicant (Counsel’s (or party’s, if unrepresented) name, address and telephone number, and fax number and e-mail address (if any))

Agent (if any) (Agent’s name, address and telephone number, and fax number and e-mail address (if any))

ORIGINAL TO: THE REGISTRAR

COPIES TO: (Name, address and telephone number, and fax number and e-mail address (if any), of every party and all other parties and interveners in the court appealed from)

NOTICE TO THE RESPONDENT: A respondent may serve and file a memorandum in response to this application for leave to appeal within 30 days after service of the application. If no response is filed within that time, the Registrar will submit this application for leave to appeal to the Court for consideration pursuant to section 43 of the Supreme Court Act.

(A notice of application for leave to appeal must be accompanied by the certificate in Form 25B and, if applicable, by the certificate in Form 25C.)