District No.

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

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

BEING SATISFIED from the application of the above-named applicant for a warrant under section 55 (2) of the above-mentioned Act, made by an information sworn before me to-day, that there are reasonable grounds for believing that a pre-school service is being carried on in the premises set out hereunder in respect of which notice has not been received by the .............. Health Board in accordance with section 51 of the Act,

I HEREBY AUTHORISE YOU .................

of .................... a person appointed by that Health Board in accordance with section e54 of the Act, to enter and inspect the premises situated at ............... in the said court district.

Dated this ..... day of ........ 19....

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

Judge of the Children Court

*(assigned to the said district)

To ..................

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

the above-named person

* Delete words inapplicable