District No.

THE INFORMATION of ......... of .......... Garda Síochána station, who says on oath:-

I am a member of the Garda Síochána and I have reasonable ground for suspecting *[that a person is in possession in contravention of the Misuse of Drugs Acts, 1977 and 1984 on *(a premises) *(land) of

*(a controlled drug, namely, .............

*(a forged prescription,)

*(a duly issued prescription which has been wrongfully altered,)

and that such *(drug) *(prescription) is on the *(premises) *(land) at ....... in said district.]

*[that opium poppy, a plant of the genus Cannabis or a plant of the genus Erythroxylon is being cultivated contrary to section 17 of the Misuse of Drugs Act, 1977 on or in the (premises) *(land) at ........ in said District.]

*(that a document mentioned in section 26 (1) (b) of the Misuse of Drugs Act, 1977 is in the possession of a person on the premises at .......... in said District.]

The ground for so suspecting is as follows:—

and I hereby apply for a warrant to search the said *(premises) *(land) pursuant to section 26 of the Misuse of Drugs Act, 1977 as amended by the Misuse of Drugs Act, 1984.

Signed ...............

Informant

SWORN before me at .................

this ... day of ....... 19 .....

Signed .....................

Judge of the District Court,

(or) Peace Commissioner

* Delete where inapplicable