FORM 81A-W
rule 81A.41(16)
File No: [file number]
RESIDENTIAL OR PASSPORT ORDER
[Offender's full name]
of [address] 
was on [date] dealt with by the Supreme Court at [Darwin / Alice Springs] which recorded a conviction for the offence(s) shown below:
CASE & OFFENCE NOS	
OFFENCE	
File number	[No]	[offence]	

AND, amongst other things, it was ordered under [section 99 of the Sentencing Act 1995 / section 22 of the Crimes Act 1914 of the Commonwealth] that the offender:
[state details of the order]
This order starts on [date] and ends on [date].
Date: [date]
JUDGE

A copy of this order must be given to the offender and the Director