Form 5. Petition for Review. DISTRICT OF COLUMBIA COURT OF APPEALS PETITION FOR REVIEW Appeal No.__________________ ________________________________, Petitioner v. _____________________ A gency No. _________________________________, Respondent (Agency) I, _______________________________, seek review by the District of Colum bia Court of Appeals of the decision or order of _________________________________ (agency) entered on the _________ day of _____________, 20____. Names, addresses, and telephone numbers of all other parties and their counsel who appeared in the agency (use additional pages if necessary): ________________________________________ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ ________________________________________________________________________ ______ __________________________________ _________________________________ Signature of Petitioner or Attorney Printed Name of Petitioner or Attorney (all but natural persons representing themselves must be represented ____________________________________ by counsel) ____________________________________ ____________________________________ A ddress ____________________________________ Telephone Number NOTE: ATTACH A COPY OF THE DECISION/ORDER ISSUED BY THE DISTRICT OF COLUMBIA AGENCY FROM WHICH THE PETITION IS TAKEN. American LegalNet, Inc. www.USCourtForms.com