Notice Of Appeal (Agency) {10-253A}

Attorney: _______________________________ ID#: ____________________________________ Address: ________________________________ City: _____________________ State: ________ Zip Code: _______________ Phone No.: ( ) _________________ Attorney for Appellant _____________________________ NAME (Appellant): ________________________ Address: ________________________________ COURT OF COMMON PLEAS Philadelphia County Term _________________________ City: _____________________ State: ________ No. ___________________________ Zip Code: _______________ Phone No.: ( ) _________________ v. _________________________________________ Agency Notice of Appeal Appellant (Please Print) ______________________________ hereby appeals from the adjudication of the ____________________________________ (Agency) made on ___________________ (Date). A Copy of Order is attached marked Exhibit "A". _________________________________ (Date) ___________________________________ (Signature) PLEASE TAKE NOTICE: All parties that entered an appearance in the proceeding before the agency may intervene as right in this appeal by filing a Praecipe to intervene within (30) days of this notice. 10-253A American LegalNet, Inc. www.FormsWorkFlow.com