Criminal Code

Canada,

Province of ,

(territorial division).

I, A.B., of , (occupation), being the appellant against conviction (or against sentence or against an order or by way of stated case) in respect of the following matter (set out the offence, subject-matter of order or question of law) undertake to appear personally at the sittings of the appeal court at which the appeal is to be heard.

(and where applicable)

I also undertake to (insert any conditions that are directed)

• (a) report at (state times) to (name of peace officer or other person designated);

• (b) remain within (designated territorial jurisdiction);

• (c) notify (name of peace officer or other person designated) of any change in my address, employment or occupation;

• (d) abstain from communicating, directly or indirectly, with (identification of victim, witness or other person) except in accordance with the following conditions: (as the justice or judge specifies);

• (e) deposit my passport (as the justice or judge directs); and

• (f) (any other reasonable conditions).

Dated this day of A.D. , at .

(Signature of appellant)