Criminal Code

Canada,

Province of ,

(territorial division).

I, A.B., of , (occupation), being the appellant against an order of dismissal (or against sentence) in respect of the following charge (set out the name of the defendant and the offence, subject-matter of order or question of law) undertake to appear personally or by counsel at the sittings of the appeal court at which the appeal is to be heard.

Dated this day of A.D. , at .

(Signature of appellant)