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FORM A

CANADA
PROVINCE OF

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    Application of (given name and surname of the applicant) made pursuant to section 672 of the Criminal Code.
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AFFIDAVIT
 
    I, the undersigned, (given names and surname of the applicant), currently detained at (name and place of the institution), in the Province of _______________________, make oath and say as follows:
    1.  I am the applicant.
    2.  The facts set out in the attached application are true.
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(Signature of applicant)
    
Sworn before me on ____________________________________________,19____________, at ________________________________in the Province of ___________________________.
 
____________________________
        Commissioner for Oaths
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