District No.

......... Prosecutor

......... Offender

I, the above-named .......... of ........ a ........ (occupation)

Principal Party hereto,

and I, ......... of ........ a ........

(occupation)

a Surety hereto,

and I, .......... of ........ a ..........

(occupation)

a Surety hereto,

severally acknowledge ourselves to owe to the State the several sums following, that is to say, the said Principal Party the sum of £ .... ,and the said Sureties the sum of £ .... each, to the use of the Minister for Finance if the Principal Party hereto fails in any condition set out hereunder.

.......... Principal Party

.......... Surety

.......... Surety

Acknowledged before me this ... day of ...... 19. .....

........................

Judge of the District Court.

CONDITIONS

The condition(s) of this recognisance is/are that the Principal Party hereto

*(a) shall be under the supervision of ........ during the period of ........ from the date of this recognisance, and will receive visits from and permit visits by the said .........*(at the Principal Party's residence) *(at ........ ) as follows:- ........;

*(b) shall undergo medical or other treatment recommended in the report made by .........;

*(c) shall for the treatment referred to at condition (b) *(attend) *(remain) in the hospital, clinic or other place at ........ for the period of .........

*(d) shall attend the following course of education, instruction or training:

...........;

* Delete where inapplicable