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)