District No.

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

of .........................

................ Respondent(s)

of .........................

TAKE NOTICE that the above-named appellant, being the *registered proprietor *person intending to be the registered proprietor of a children's residential centre situated at ................. in the functional area of the respondent health board and in the said court district, will appeal at the sitting of the District Court to be held at .................. on the ..... day of ............ 19 .... at ....... a.m./p.m. under section 62 of the above-mentioned Act against the decision of the board—

*(to refuse to register the centre,)

*(to remove the centre from the register,)

*[*(to attach a condition) *(to amend/revoke a condition attached) to the registration of the centre,] made on the .... day of ........... 19.... and notification of which was received by the appellant on the ..... day of .............. 19....

Dated this.............. day of................... 19.............

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

Appellant

To ..................

of ..................

the above-named health board.

* Delete words inapplicable