to be made and levied of their several goods and chattels, lands and tenements respectively, to the use of Her Majesty the Queen, if the said accused fails in any of the conditions hereunder written.

Taken and acknowledged before me at the   of   on the   day of  , 20 , at   a.m./p.m..

WHEREAS the said   , hereinafter called the accused, has been charged that he/she on or about the  day of  , 20 , at the  of  , unlawfully did commit the offence of  .

NOW THEREFORE, the condition of this recognizance is that if the accused attends at the time and place fixed by the court and attends therefore as required by the court in order to be dealt with according to the law, AND FURTHER, if the accused:
(strike out the inapplicable words)

1. )  reports at  (state times) to  
   (name of police officer or other person designated),
2. )  remains within  (designated territorial jurisdiction),
3. )  notifies   (name of peace officer or other person designated) of any change in his/her address, employment or occupation,
4. )  abstains from communicating with  (name of witness or other person) except in accordance with the following conditions:
    
    
     (as the Justice or Judge specifies),
5. )  deposits his/her passport 
   (as the justice or judge directs) and
6. )  does not possess during the term of the recognizance, any firearm, cross-bow, prohibited weapon, restricted weapon, prohibited device, ammunition, prohibited ammunition, or explosive substance or
7. ) does not possess, during the term of the recognizance, any of the foregoing items except for
    
    
    
   (any other reasonable conditions)

the said recognizance is void, otherwise it stands in full force and effect.

Assuming that it would otherwise apply, s.115 of the Criminal Code shall not apply to this order.

A COPY OF THIS ORDER SHALL BE SENT TO THE CHIEF FIREARMS OFFICER.