District No.

THE INFORMATION of ............. of ............, who says on oath—

I am a member of the Garda Síochána not below the rank of sergeant.

I believe that there are reasonable grounds for suspecting that—

( a ) an offence under the above-mentioned Act or an offence referred to in section 16 (2) of that Act has been or is being committed *(on the premises) *(at the place ........... ) at .............., in the court (area and) district aforesaid, and

( b ) evidence that the offence has been or is being committed is *(on those premises) *(at that place)

The basis for my so believing is as follows:—

and I hereby apply for the issue of a warrant under section 25 of that Act in respect of the said *premises *place.

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

Informant

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

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

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

Judge of the District Court

(or) Peace Commissioner

*Delete words inapplicable.