District No.

WHEREAS I am satisfied by the information on oath of ....... a member of the Garda Síochána, of ....... Garda Síochána station,

that there is 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 Eryhroxylon 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,]

THIS IS TO AUTHORISE YOU, ......... , the said member of the Garda Síochána, accompanied by such other members of the Garda Síochána and such other persons as may be necessary, at any time or times within one month of the date hereof, to enter (if need be by force) the said *(premises) *(land) at .......... in said district, to search such *(premises) *(land) and any persons found therein, to examine any substance, article or other thing found thereon or therein, to inspect any book, record or other document found thereon and, if there is reasonable ground for suspecting that an offence is being or has been committed under the Misuse of Drugs Acts, 1977 and 1984 in relation to a substance, article or other thing found on such (premises) (land) or that a document so found is a document mentioned in subsection (1) (b) of section 26 of the Misuse of Drugs Act, 1977 or is a record or other document which you have reasonable cause to believe to be a document which may be required as evidence in proceedings for an offence under the Misuse of Drugs Acts, 1977 and 1984, to seize and detain the substance, article, document or other thing, as the case may be.

Dated this day of 19.

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

Judge of the District Court,

(or) Peace Commissioner.

To ................

of ...............

* Delete where inapplicable