Court File No.___________

PROVINCIAL COURT
(SPECIFY COURT LOCATION) 
(Criminal Division)

BETWEEN:

HER MAJESTY THE QUEEN
(indicate whether applicant or respondent)

-and-

(SPECIFY NAME OF ACCUSED)
(indicate whether applicant or respondent)
 

NOTICE OF APPLICATION FOR CHANGE OR REVOCATION OF RELEASE ORDER


       TAKE NOTICE that an application will be brought on _____ day, the ______ day of ___________________ (specify month), 20____, at ___________ (time of day) or as soon thereafter as the application can be heard at ________________________________________________________________ (specify address of court house and courtroom number if known), for an order to vacate the release order made the ________ day of _______________ (specify month) 20______, made pursuant to the provisions of Part XVI of the Criminal Code by ________________________ (name of Judge/Justice).

* The conditions sought to be changed are: (check if applicable)
Clauses _________

* The conditions sought to be deleted are:
Clauses _________

* The existing release order vacated and replaced with a new release order pursuant to the provisions of Part XVI of the Criminal Code.

The above noted changes are sought for the following reasons:



IN SUPPORT OF THIS APPLICATION THE APPLICANT RELIES UPON THE FOLLOWING:

1.	(Set out documents such as affidavits or other documents upon which the Applicant relies).


DATED at ________________________ this __________ day of _________________ 20_____.


__________________________________________
(Signature of applicant or counsel - set out name, address as well as telephone and fax number)