Rules of the Supreme Court of Canada

TAKE NOTICE that, pursuant to the order of the Chief Justice (or other judge) made on (date), the constitutional question(s) in the appeal from the judgment of the (name of court appealed from) made on (date), are attached to this Form;

AND TAKE NOTICE that any notice of intervention in Form 61B in the appeal must be served on all other parties and filed with the Registrar of the Supreme Court of Canada within four weeks after the service of this notice.

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

SIGNED BY (signature of counsel or party or agent)

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

Agent (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 attorneys general)

(Attach a copy of the order of constitutional question(s) and reasons for the judgment appealed from.)