In the District Court of

No.                       of 19            .

Between

A. B.,

Plaintiff,

and

C. D.,

Defendant.

Ex Parte A.B., of                                  , Applicant.

The above applicant applies for (a)                                  .

The application is based on (b)                                  .

*The facts relied upon are as follows : (c)

or

*(The facts relied upon are set forth in the accompanying affidavit by A.B. dated                                  .)

This application is made by A.B. in person, (or by E.F., advocate for A.B.). Address for service:

(Signed)                                 

Advocate for Applicant.

Filed on the                       day of                                  19            .

Fixed for hearing on the                       day of                                  19            , at                       o'clock in the                       noon.

Registrar.                      

(a) Set out order or direction applied for.

(b) Set out specific section of Law or specific Rule of Court.

(c) If the application is not required by the rules to be supported by affidavit, the facts relied upon should be stated in the application.

* Strike out if not required.