Address, Phone Number:

Name, Address, Phone
Number of Counsel

Date of Conviction:

Date of Sentence:

Place of Incarceration
(if in custody):

Name of Judge:

Please List all Drug
Certificate Numbers
Entered into Evidence
on your matter
(please indicate number(s) exactly):

Position regarding the identification of the substance at trial (if you admitted the nature of the substance at trial, please attach your affidavit or statutory declaration setting out the exceptional circumstances why your admission should be set aside):

Was the certificate(s) tendered in evidence at trial?

Did the Analyst testify? If so, was leave to cross-examine sought?

Did you introduce evidence contesting the identification of the substance as described in the certificate?

How, if at all, would the new information with respect to the certificate(s) have affected the result or the fairness of the trial process?

Are materials available with respect to the court proceeding? (ie - trial transcripts, reasons for judgment)

Reason(s) for plea:

Did you have a defence on the merits to the charge relating to the nature of the substance?

Are materials available with respect to the court proceeding? (ie - trial transcripts, reasons for judgment)