District No.

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

.................. Respondent

(the issuing authority)

TAKE NOTICE that the above-named appellant of ......................... in court area and district aforesaid,

INTENDS TO APPEAL to the District Court at .................. on the .... day of .....19 at ......m.

*(against the above-named issuing authority's refusal, under section 33 (3) (a) of the Act, to carry out a test.)

*(against the above-named issuing authority's deferring of a decision, under section 33 (4) of the Act, pending the production of a certificate of fitness.)

*(against the above-named issuing authority's decision under section 33 (4) of the Act.)

Dated this day of 19 .

Signed ..........................

Appellant/Solicitor for Appellant

To the Issuing Authority of the

at

Respondent

*(To

of ).

* Delete where inapplicable