TAKE NOTICE THAT, I            of        being aggrieved by the (refusal of the Director to grant a licence)* (decision by the Director to revoke a licence)* (decision by the Director to suspend a licence)* (decision by the Director to amend a licence)* (decision by the Director to impose specific measures under section 111(4)(a) of the Postal and Telecommunications Services Act, 1983 , on the holder of a licence)* hereby appeal against such (refusal)* (decision)* to the Judge sitting at the (District)* (High)* Court to be held on the day of , 19 .

*Delete where not applicable.

Dated this day of , 19 .

Appellant

Solicitor for the Appellant

(To the District Court Clerk at)*

(To the High Court Registrar at the Central Office, Four Courts, Dublin)

*To the Director, Office of the Director of Telecommunications Regulation, Abbey Court, Irish Life Centre, Lower Abbey Street, Dublin 1.

*Delete where not applicable.]