District Court Area of
District No.
Record number:

In the matter of section ......of the .....[insert details of the relevant enactment relied on]

Between

........ Appellant

........ Respondent

TAKE NOTICE that the above-named appellant, of ........ will appeal at the sitting of the District Court to be held at........ on the ...... day of ........ 20.... at ........ a.m./p.m. from the *notice *decision * direction of the respondent, of ........ *served *given on the ...... day of ........ 20.... at ........ *in the above Court *(area and) district aforesaid under section ...... of the ........ (title of enactment)

whereby ........ (give details of the notice, decision or direction appealed from)

And the appellant will apply for [Specify any further or consequential relief or orders sought in accordance with the enactment e.g. An order granting the applicant a licence to ........ , etc]

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. prohibition notice	1 September 2013	Prohibition notice issued by the respondent to the appellant
2	e.g. letter	1 September 2013	Letter by the respondent sending the prohibition notice 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