State Act Regulation (Full Under what No. Ref.) law? Commonwealth Regulation Other— specify Are there more No Yes—see charges? "Continuation of Charges" attached Type of offence Summary offence Indictable offence Request for No Yes committal proceeding Who filed the charge-sheet(s)? Name of Informant: Agency and Address: Phone: Email: Fax No.: Agency Ref.: Signature of Informant: Date: Filed at: Date: 2 Rule 11 Page No.
Under what law? State Act Regulation No. (Full Ref.) Commonwealth Regulation Other— specify Are there more charges? No Yes—see "Continuation of Charges" attached Type of offence Summary offence Indictable offence Request for committal proceeding No Yes Who filed the charge-sheet(s)? Name of Informant: Agency and Address: Phone: Email: Fax No.: Agency Ref.: Signature of Informant: Date: Filed at: Date: 2 Rule 11 Page No.
09-181sr013.docx