Notice of intervention is hereby given by (here insert name and full postal address of Intervener)

........................................................................................................................

...................................................................on the appeal of (here insert name of Appellant)

.................................................................

made on the (here insert the date of the notice of appeal) ....................... day of...........

A. Statement of Facts (*)

(Admit or deny the facts alleged in the notice of appeal and set out in consecutively numbered paragraphs a statement of such further facts upon which the Intervener intends to rely.)

B. The Reasons which the Intervener Intends to Submit (*)

(Here set out the reasons on which the Intervener intends to rely.)

C. Address for Service

(Here set out the address for service of documents: (**)

• (a) name and address of Intervener’s counsel, if any, or

• (b) name and address of Intervener’s agent, if any.)

Dated at (city, town or village), this day of 20

(*) Attention is directed to subsection 9(3) of these rules, which permits Interveners, instead of setting forth a statement of facts and reasons, to rely on the statements of facts and reasons pleaded in the notice of appeal or any other intervention.

(**) If the Intervener is not represented by a counsel or an agent, the address given at the commencement of the notice of intervention shall be the Intervener’s address for service.