FORM 81A-F
rule 81A.40(4)
   
File No: [File Number]
      Judge: [Name] J	
CERTIFICATE OF CONVICTION
I, [full name of Deputy Sheriff], Deputy Sheriff, an officer having the care, custody and control of the criminal records of the Supreme Court of the Northern Territory, hereby certify that on [sentencing date] at [Darwin / Alice Springs] in the Northern Territory, [full name of convicted person] and [date of birth] was found guilty by this Honourable Supreme Court of the Northern Territory at [place] which recorded a conviction that [he/she]:
COUNT 1: 
[state count and relevant Act]
COUNT 2:
[state count and relevant Act]
AND upon being convicted [he/she] was sentenced to [state period of imprisonment or otherwise].
AND it was further ordered that: [state any further orders, for example, the imprisonment is to be served in the community subject to the terms of a [order]]. 

Date: [date]

at [Darwin / Alice Springs] in the Northern Territory.
DEPUTY SHERIFF