District No.

................... Applicant

THE INFORMATION of ....................................

of .......................................

who says on oath—

I am the applicant herein I have been authorised by the ..................... Health Board to make this information.

I believe that a pre-school service is being carried on in the premises situated at ............. in the said court district in respect of which notice has not been received by the said health board in accordance with section 51 of the above-mentioned Act and I hereby apply for the issue of a warrant under section 55 (2) of the Act authorising me to enter and inspect the said premises.

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

Informant

Sworn before me this .... day of ......... 19 .... at ...............

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

Judge of the Children Court

*(assigned to the said district)

* Delete words inapplicable