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Dated this ............... day of ............... A.D. ....., at ............... .
Dated this ............... day of ............... A.D. ....., at ............... .
Dated this ................... day of .................... A.D. .................... , at ...................... .
If you are found to have contravened this order, you may be subject to a fine or imprisonment, or to both.