A.B. Take notice that in the event of your being convicted of the charge of contravening (give reference to the section of Act or Order) in the complaint preferred against you at my instance it is intended to place before the Court the undernoted previous convictions applying to you and you will be liable (in respect that the offence is a second [or third] offence) to the penalties set forth in the said section [or in section of the said Act] namely (set forth shortly the penalties).