Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

I (name), (occupation), of in (territorial division), apply for the issuance of a summons under section 485.2 of the Criminal Code requiring (name of accused or offender) to attend at a time and place stated in it for the purposes of the Identification of Criminals Act.

(Name of accused or offender) was previously required to appear on (date) at (hour) at (place) for the purposes of the Identification of Criminals Act under (a summons or an appearance notice or an undertaking or an order) issued on (date) in relation to (set out briefly the offence in respect of which the accused or offender was previously required to appear).

• □ (Check if applicable) The offence which is currently the subject of the proceedings, namely (set out briefly the offence for which the accused is currently charged or the offender has been determined to be guilty) is different from the offence listed above, but stems from the same matter for which the accused or offender was previously required to appear under that Act, and is an offence referred to in paragraph 2(1)(c) of that Act.

The measurements, processes and operations referred to in that Act were not completed for the following reason(s):

(set out reason(s))

Sworn before me on (date), at (place).

(Signature of applicant)

(Signature of judge, justice or clerk of the court)