| (Section 4(3)) |
| CERTIFICATE OF SAMPLE OF SEIZED SUBSTANCE |
| I HEREBY CERTIFY that on the day of |
| 20 , I took a sample of from the bulk and |
| that the bulk was weighed or otherwise measured and the sample was taken and weighed or otherwise measured in the presence of |
| | |
| (Name) | (Address) |
| *Accused/*Attorney-at-law/*Agent |
| Measurement of bulk g/kg/ml/l. |
| Measurement of sample g/kg/ml/l. |
| Signature and Rank |
| Police Officer |
| Signature *Accused |
| | *Attorney-at-law |
| | *Agent |
| (*delete if inapplicable) |