FORM 36 (Sections 570 and 806)
Order Against an Offender
Canada,
Province of ,
(territorial division).
Be it remembered that on the day of A.D. , at , A.B., (date of birth) of , was tried on an information (indictment) alleging that (set out matter of complaint or alleged offence), and it was ordered and adjudged that (set out the order made).
Dated this day of A.D. , at
Justice or Clerk of the Court