*District No.

*Dublin Metropolitan District

WHEREAS …………… of ………………. was detained in the place of detention at ………… in District Court District No. ... of the District Court pursuant to the provisions of *subsection (8) *subsection (13) of section 9 of the above mentioned Act,

AND WHEREAS it was ordered by the District Court Judge assigned to the district where said place of detention is situated on ….. day of ………… 20……, that the person above-named be released from the said place of detention subject to the following condition(s):-

(I) that he/she resides or remains *in District No. …. of the District Court or *in …………………………… in the State,

(II) that he/she reports to the Garda Síochána Station at …………… or immigration officer at …………….. at the following times ………….

(III) That he/she surrenders any passport or travel document in his/her possession.

(IV) That …………………..

(here insert any other conditions imposed)

TAKE NOTICE that ………… of …………….

*the person above-named

*an immigration officer

*a member of the Garda Síochána

will apply to a Judge of the District Court assigned to the District Court District in which the person above named resides, at a sitting of the District Court at …………… in the District Court District in which the person above-named resides) on the … day of ……… 20 … at …….. a.m/p.m., for an order varying the condition numbered *(I), *(II), *(III), *(IV) listed above as follows:-

Dated this … day of …………….. 20…..

____________

Applicant

To ………………….

*Delete words inapplicable