FIRST JUDICIAL DISTRICT OF PENNSYLVANIA COURT OF COMMON PLEAS OF PHILADELPHIA COUNTY Notice of Appeal from Summary Conviction ­ Traffic APPELLANT/DEFENDANT'S LAST NAME ADDRESS CITY FIRST NAME EMAIL ADDRESS STATE ZIP CODE IF APPEALING NUNC PRO TUNC, ENTER: CPCMS NO. CP-51-SA-_ _ _ _ _ _ _- _ _ _ _ CP-51-MD-_ _ _ _ _ _ _- _ _ _ _ DATE OF SENTENCE/ORDER Appellant/Defendant appeals the following traffic citations: CITATION NO. . ISSUE DATE OFFICER BADGE NO. . OFFENSE Check if appealing nunc pro tunc Check if appealing a negotiated plea Check if appealing imposition of prison sentence ATTORNEY NAME ADDRESS CITY STATE EMAIL ADDRESS Check if appealing payment plan order PA SUPREME COURT ID ZIP CODE Appellant's/Attorney's Signature: __________________________________________ Date: _______________________ FOR COURT USE ONLY Negotiated Plea Guilty In Absentia Convicted of Different Offense Nunc pro tunc Appeal HEARING NOTICE A status or settlement conference is scheduled as provided below. A de novo trial is scheduled as provided below. Law enforcement officer to be subpoenaed. Continuances subject to Rule 106. _______________________, at __________ AM/PM in Courtroom _________, 800 Spring Garden St., Philadelphia, PA 19123. APPELLANT/DEFENDANT PLEASE NOTE: YOUR APPEAL MAY BE DENIED OR DISMISSED IF YOU FAIL TO APPEAR FOR THE CONFERENCE OR TRIAL FOR THE COURT: Date:_______________________________ _______________________________________________ NOTICE TO THE APPELLANT/DEFENDANT OR ATTORNEY RECEIPT OF A COPY OF THE NOTICE OF APPEAL CONSTITUTES PERSONAL SERVICE ON YOU A COPY OF THE NOTICE OF APPEAL AND HEARING ORDER WAS RECEIVED BY (Appellant or Appellant's Attorney must sign below): Name: Date: If your appeal is from a motor vehicle conviction, have the Office of Judicial Records certify this copy and mail to the following address: PennDOT, Correspondence Unit, P.O. Box 68618, Harrisburg, PA 17106 I hereby certify than an appeal has been filed in the above-captioned case(s). _________________________________ Office of Judicial Records 02-47 (Rev. 3/02/15) American LegalNet, Inc. www.FormsWorkFlow.com