| CARICOM STANDARD | MEMBER STATE |
| FLAG |
| CARICOM ARREST WARRANT |
| [LEGAL AUTHORITY] |
| I hereby certify that this warrant corresponds to the authentic documents on which the warrant is based and request that the person mentioned below be arrested and surrendered to the central authority mentioned below: |
| (a) Information regarding the identity of the requested person: |
| Surname: |
| First Name |
| Other Name(s) |
| Sex: |
| Nationality: |
| Date of birth: |
| Place of birth: |
| Residence : |
| Distinctive marks: |
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| Photo and fingerprints of the requested person (if available): |
| (b) The central authority, of country which issued the request, and to which the person shall be surrendered: |
| Name of the authority: |
| Competent official (title/rank and name): |
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| Address: |
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| Tel. No.: Fax No.: |
| Email: |
| (c) Enforceable criminal judgment or other judicial decision, within the scope of the CARICOM Arrest Warrant Treaty and section [ ] of the [CARICOM Arrest Warrant Act]: |
| Type: |
| Date: |
| (d) Nature and legal classification of the offence: |
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| (e) Description of the circumstances in which the offence was committed, including the time, place and degree of participation in the offence by the person reported: |
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| (f) The penalty, if there is an enforceable criminal judgment, or the prescribed penalty, and, if possible, other consequences of the offence or the offences: |
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| (g) Other consequences of the offence, particularly as regards the situation of the victim: |
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| (h) Has the person already been arrested for the same offence? Has the person escaped from custody? |
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| (i) Other information: |
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| Signature of the issuing judicial authority: |
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| Title/rank and name: |
| Date |
| NOTE: This warrant must be written in, or translated into, the official languages of the executing State. |
| [Court Seal] |