In the Magistrate's Court for the District/Region of ...................................................................................

held at ................................................. Case No. ........................................ of 20.........

In the matter between

..................................................................................................................... Plaintiff

and

................................................................................................................. Defendant

The plaintiff/defendant hereby applies to have the above action tried with assessors.

(1)        The defendant/plaintiff consents to such application and to the appointment of the following assessor:

.......................................................................................................................................... of

..............................................................................................................................(address)

....................................................................

Plaintiff/Plaintiff's Attorney

..................................................................

Defendant/Defendant's Attorney

or

(2)        The defendant/plaintiff consents to such application, but the parties are unable to agree upon the names of assessors.

Wherefore the parties pray the court to appoint an assessor (or two assessors) excluding the following assessors (set out the names of those assessors whom one or other of the parties objects to):

...................................................................

Plaintiff/Plaintiff's Attorney

..................................................................

Defendant/Defendant's Attorney

or

(3)        The defendant/plaintiff objects to such application.

Wherefore the plaintiff/defendant has set down this application for hearing on the ........................... day of ................................., 20....... at ................ (time) ........................................................................

Plaintiff/Defendant or Plaintiff's/Defendant's Attorney

To: The Registrar/Clerk of the Court.

And: .............................................................................................................................

Application granted/refused this ......................... day of ..........................., 20..........

Assessors appointed:

.................................................................

Registrar/Clerk of the Court