Court File No.___________
PROVINCIAL COURT
(SPECIFY COURT LOCATION) 
(Criminal Division)

BETWEEN:

HER MAJESTY THE QUEEN

-and-

(SPECIFY NAME OF ACCUSED)

NOTICE OF APPLICATION AND CHARTER/CONSTITUTIONAL ISSUE

	TAKE NOTICE that the (identify party) will bring an application on ______ day, the _____ day of (specify month). 20____. at (time of day) or as soon thereafter as this application can be heard at (specify address of court house and courtroom number if known), for an order granting:

	THE RELIEF SOUGHT IS:
		1.	An Order allowing the applicant and granting (indicate precise relief sought)

	THE GROUNDS FOR THIS APPLICATION ARE:
		1.	That...
		2.	Such further and other grounds as counsel may advise and this Honourable Court may permit.

	THE CHARTER/CONSTITUTIONAL ISSUES TO BE RAISED ARE:
	1.	(state concisely each issue to be raised)
	2.	. . .

	THE CHARTER/CONSTITUTIONAL PRINCIPLES TO BE ARGUED ARE:
	1.	. . .
	2.	. . .

	THE STATUTORY PROVISIONS OR PRACTICE DIRECTIVES UPON WHICH THE APPLICANT RELIES ARE:
	1.	. . .

	IN SUPPORT OF THIS APPLICATION, THE APPLICANT RELIES UPON THE FOLLOWING:
		1.	(briefly describe the documents such as affidavits, transcripts, etc., upon which the Applicant relies)

	THE APPLICANT MAY BE SERVED WITH DOCUMENTS PERTINENT TO THIS APPLICATION
		1.	By service in accordance with Practice Directive 5, through (specify address and fax number)

	DATED at _____________________ this _________ day of _________ 20____.

___________________________________________
(signature of applicant or counsel) (set out name and address, as well as telephone and fax numbers)

_____________________________
Issued by Staff Justice of the Peace