To a District Court Judge at [specify]

I, [name, occupation, and address of applicant] hereby make application for an order under section 8 of the Alcoholism and Drug Addiction Act 1966. I desire to be received into the institution situated at [specify] and known as [name of institution] and I undertake to remain in that institution for treatment for alcoholism *(or addiction to drugs) until I am released or discharged under that Act.

Whereas [name, occupation, and address of applicant] has made application under section 8 of the Alcoholism and Drug Addiction Act 1966 for an order under that section; and has specified the institution situated at [specify] and known as [name of institution], as the institution into which he desires to be received:

And whereas the said [name of applicant] has appeared before me and I am satisfied that the said [name of applicant] is an alcoholic *(or drug addict) and that he fully understands the nature and effect of his application and that the managers *(or superintendent) of that institution *are (is) willing to receive the said [name of applicant] into that institution:

Now, therefore, I do order that the said [name of applicant] be detained, for treatment for alcoholism *(or addiction to drugs), in the institution situated at [specify] and known as [name of institution].

To a District Court Judge at [specify]

I, [name, occupation, and address of applicant] hereby make application pursuant to section 9 of the Alcoholism and Drug Addiction Act 1966 in respect of [name, occupation, and address of person to whom the application relates], hereinafter in this application referred to as the said person; on the grounds that the said person is an alcoholic *(or drug addict).

I believe that the said person is an alcoholic *(or drug addict) because [set out full reasons for applicant’s belief]:

I am [insert degree of relationship, if any or words “not related”] to the said person.

[To be completed only if the applicant is not a relative† of the said person]: This application is made by me instead of by a relative because [state reason]:

Under section 9(3) of the Alcoholism and Drug Addiction Act 1966 I, [insert name, place of abode, and occupation of applicant or other person making declaration] solemnly and sincerely declare that the statements contained in the foregoing application under section 9 of the Alcoholism and Drug Addiction Act 1966 are true (add “to the best of my knowledge and belief” if declaration is made by person other than applicant). And I make this solemn declaration conscientiously believing the same to be true and by virtue of the Oaths and Declarations Act 1957.

To [full name] of [address and occupation]

[Full name] of [address and occupation] has stated that you the said [full name] are an alcoholic* (or drug addict).

You are summoned to appear on [date] at [time] am (pm) before a District Court Judge at the District Court at [specify] to show cause why an order should not be made requiring you to be detained for treatment for alcoholism* (or drug addiction) in an institution.

Note: Section 35(1) of the Alcoholism and Drug Addiction Act 1966 provides that every application under that Act shall be heard and determined in private.

To every constable:

In an application dated [date] and made under section 9 of the Alcoholism and Drug Addiction Act 1966 it has been stated that [full name] of [address and occupation] is an alcoholic* (or drug addict).

†I am satisfied, by evidence on oath, that a warrant is necessary to compel the attendance of the said [full name] to show cause why an order should not be made requiring him to be detained for treatment for alcoholism* (or drug addiction) in an institution:

†or I am satisfied, by evidence on oath, that circumstances exist that render the issue of a warrant expedient;

†or I am satisfied that the said [full name] has refused to undergo examination by 2 medical practitioners for the purposes of the Alcoholism and Drug Addiction Act 1966;

†or I am satisfied that the said [full name] has wilfully failed to attend for a medical examination required for the purposes of the Alcoholism and Drug Addiction Act 1966:

And I direct you to arrest the said [full name] and bring him before a District Court Judge as soon as possible, to be dealt with in accordance with the Alcoholism and Drug Addiction Act 1966;

†And I further direct that the said [full name] shall, after his arrest, undergo medical examination by [specify] and [specify] being 2 medical practitioners.

I, [name and address of medical practitioner], being a medical practitioner registered in New Zealand, do hereby certify that I believe [name, occupation, and address of person to whom the certificate relates] is an alcoholic within the meaning of the Alcoholism and Drug Addiction Act 1966 *(or a drug addict within the meaning of the Alcoholism and Drug Addiction (Forms) Regulations 1968) and that the making of an order for his detention and treatment as such is expedient in his own interest *(or in the interest of his relatives).

The following are the reasons for my said belief [set out reasons in full]:

I hereby declare that I am not prohibited by section 32 of the Alcoholism and Drug Addiction Act 1966 from signing this certificate.

Whereas [name, occupation, and address of applicant] (being a relative of [name of person to whom the application relates])† has made an application dated [date] pursuant to section 9 of the Alcoholism and Drug Addiction Act 1966 in respect of [name, occupation, and address] on the grounds that the said [name] is an alcoholic *(or drug addict):

And whereas [name and address of medical practitioner] and [name and address of medical practitioner] have given evidence *(or certificates in the prescribed form) to the effect that they believe the said [name] to be an alcoholic *(or drug addict) and that his detention and treatment as such is expedient in his own interest *(or in the interest of his relatives):

And whereas the said [name] has appeared before me and I am satisfied that the said [name] is an alcoholic *(or drug addict) and that the managers *(or superintendent) of the institution situated at [specify] and known as [name of institution] are *(is) willing to receive the said [name] into that institution:

Now, therefore, I do order that the said [name] be detained for treatment of alcoholism *(or addiction to drugs) in the institution situated at [specify] and known as [specify]