______________________           V.         HER MAJESTY THE QUEEN 
Appellant/Accused                                      Respondent

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Court File No. _________

Lower Court No. _____________

                                     
                                      ONTARIO COURT OF APPEAL

                                      (proceedings commenced 

                                      (in _________________) 









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                                         NOTICE OF APPEAL
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                                   For the Appellant: 

                                   Name: _____________________________

                                   Address: __________________________

                                   ___________________________________

                                   Tel: ______________________________

                                   Fax: ______________________________