Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

To the peace officers in the (territorial division) and to the keeper of the (prison) at :

Whereas A.B., hereinafter called the defendant, was tried on an information alleging that (set out matter of complaint), and it was ordered that (set out the order made), and in default that the defendant be imprisoned in the (prison) at for a term of ;

You are directed, in Her Majesty’s name, to arrest, if necessary, and take the defendant and convey them safely to the (prison) at , and deliver them to the keeper of the prison, together with the following precept:

You, the keeper of the prison, are directed to receive the defendant into your custody in this prison and keep them safely there for the term of , unless the amounts and the costs and charges of the committal and of conveying the defendant to the prison are sooner paid, and for so doing this is a sufficient warrant.

Dated (date), at (place).

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