Rules of the Supreme Court of Canada

TAKE NOTICE that (name) applies for leave to appeal to the Court, under (cite the legislative provision or provisions that authorizes the application for leave), from the judgment of the (name of the court appealed from and file number from that court) made (date), and for (insert the nature of order or relief sought);

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), (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 email address (if any))

Agent (if any) (Agent’s name, address and telephone number, and fax number and email address (if any))

ORIGINAL TO: THE REGISTRAR

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

NOTICE TO THE RESPONDENT OR INTERVENER: A respondent or intervener may serve and file a memorandum in response to this application for leave to appeal within 30 days after the day on which a file is opened by the Court following the filing of this application for leave to appeal or, if a file has already been opened, within 30 days after the service of this application for leave to appeal. If no response is filed within that time, the Registrar will submit this application for leave to appeal to the Court for consideration under section 43 of the Supreme Court Act.

(A notice of application for leave to appeal shall be filed at the same time as the certificate in Form 23A and, if applicable, the certificate in Forms 23B or 23C.)