CERTIFICATECERTIFICATE

CERTIFICATE

I, (insert the full name of the Minister), Minister of State for Foreign Affairs and Trade, certify that the presence of the following prescribed objects:

(insert a description of the prescribed objects)

on prescribed land or premises, being (insert a description of the land or premises), impairs or (if it were to take place or continue) would impair, the dignity of the mission or of the residence of the head, or another diplomatic agent, of the mission and that its removal would be an appropriate step to prevent the impairment or the continuation of the impairment (here insert a description of the mission or residence).

This certificate was signed (insert time and date of signature) and has effect

* from that time and date

* from (insert time and date from which certificate is to have effect).

(signature of Minister)

Minister of State for Foreign Affairs and Trade

* Omit if inapplicable.