Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of ,

(territorial division).

Whereas on the day of at , A.B., hereinafter called the offender, (pleaded guilty to or was tried under (here insert Part XIX, XX or XXVII, as the case may be) of the Criminal Code and was (here insert convicted or found guilty, as the case may be) on the charge that (here state the offence to which the offender pleaded guilty or for which the offender was convicted or found guilty, as the case may be);

And whereas on the day of the court adjudgedFootnote ^*

• Return to footnote ^*Use whichever of the following forms of disposition is applicable:

• (a) that the offender be discharged on the following conditions:

• (b) that the passing of sentence on the offender be suspended and that the said offender be released on the following conditions:

• (c) that the offender forfeit and pay the sum of dollars to be applied according to law and in default of payment of the said sum without delay (or within a time fixed, if any), be imprisoned in the (prison) at for the term of unless the said sum and charges of the committal and of conveying the said offender to the said prison are sooner paid, and in addition thereto, that the said offender comply with the following conditions:

• (d) that the offender be imprisoned in the (prison) at for the term of and, in addition thereto, that the said offender comply with the following conditions:

• (e) that following the expiration of the offender’s conditional sentence order related to this or another offence, that the said offender comply with the following conditions:

• (f) that following the expiration of the offender’s sentence of imprisonment related to another offence, that the said offender comply with the following conditions:

• (g) when the offender is ordered to serve the sentence of imprisonment intermittently, that the said offender comply with the following conditions when not in confinement:

Now therefore the said offender shall, for the period of from the date of this order (or, where paragraph (d), (e) or (f) is applicable, the date of expiration of the offender’s sentence of imprisonment or conditional sentence order) comply with the following conditions, namely, that the said offender shall keep the peace and be of good behaviour, appear before the court when required to do so by the court and notify the court or probation officer in advance of any change of name or address and promptly notify the court or probation officer of any change of employment or occupation, and, in addition,

(here state any additional conditions prescribed pursuant to subsection 732.1(3) of the Criminal Code).

Dated this day of A.D. , at .

Clerk of the Court, Justice or Provincial Court Judge