Please Print
I,
[name],
of
[city, town, municipality],
in the Province of
,
was convicted for
[name of offence]
in relation to
[specifics of offence]
on
[date of conviction].
I am submitting an application under sections 696.1 to 696.6 of the Criminal Code for a review of this conviction.
These are the names and addresses of all counsel who represented me in court proceedings in relation to the charge and conviction:
By signing this document, I waive any solicitor-client privilege to which these counsel are subject. They may discuss any aspect of the case with any designated representative of the Minister of Justice while my application is being assessed.
I understand that waiving my solicitor-client privilege means that my counsel:
I sign this waiver voluntarily.
Applicant's Signature
Date
Witness's Signature
Full Name of Witness
Province
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