To the Minister of Health
Take notice that I, [full name, address] hereby appeal under section 23 of the Radiation Protection Act 1965 against the decision of the Director-General of Health conveyed to me by letter dated [date].
I make my appeal on the following grounds: [specify].
And I hereby appoint [full name, address] as assessor on my behalf for the purposes of this appeal.
Dated at [place, date]
I hereby consent to act as assessor for the purposes of this appeal.
Signature of assessor: