______________________      V.              HER MAJESTY THE QUEEN 
Applicant/Accused                                      Respondent

_________________________________________________________________

Court File No. _________

Lower Court No. _____________

                      
                                      ONTARIO COURT OF APPEAL

                                      (proceedings commenced 

                                      (in __________________) 









                                       ---------------------
                                       RECORD OF APPLICATION
                                       FOR EXTENSION OF TIME
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                                   For the Applicant: 

                                   Name: ________________________

                                   Address: _____________________

                                   ______________________________

                                   Tel: _________________________

                                   Fax: _________________________