District No.

THE INFORMATION OF ........ of ............,

who says on oath—

I am a member of the Garda Síochána

I say that there is reasonable ground for believing that an offence under section 9 or 10 of the above-mentioned Act is taking or has taken place in the place ........... in the court (area and) district aforesaid.

The basis for such belief is as follows:—

and I hereby apply for the grant of a search warrant under section 14 of that Act in respect of the above-named place.

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

Informant

SWORN before me this ... day of ......... 19 ....

at .......................

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

Judge of the District Court