District Court Area of
District No.
Record number:

........... Appellant

........ Mental Health Commission ........ Respondent

TAKE NOTICE that the above-named appellant, ........ of ........ being *the registered proprietor *the person intending to be the registered proprietor of an approved centre (within the meaning of section 63 of the above-named Act) situated at ........ in the above Court district, will appeal at the sitting of the District Court to be held at ........ on the ...... day of ........ 20.... at ........ a.m./p.m., from a decision of the above-named respondent, the Mental Health Commission, under section 64 of the Mental Health Act 2001 of which the appellant received notification on ........ 20.... (being within 21 days of the date of this appeal)

*to refuse to register the said centre

*to remove the said centre from the register

*to attach a condition to the registration of the said centre

*(to amend) *(to revoke) a condition attached to the registration of the said centre

The grounds for the appeal are as follows: ........ [set out in summary the grounds of the appeal].

Particular legal provisions relied on in the appeal ........ [identify any particular legal provisions relied on in the appeal].

	Document	Date	Description
1	e.g. decision notice	1 September 2013	Decision issued by the respondent to the appellant
2	e.g. letter	1 September 2013	Letter by the respondent sending the decision to the appellant
Etc

*(Solicitor for the) appellant

To: District Court Clerk at ........

And: ........ *(Solicitor for the) respondent

of ........

This notice of appeal has been filed with the District Court Clerk at ........ and issued on the ...... day of ........ 20....

*delete where inapplicable