332
-40-
Serial No.
(FOR RECORD IN THE HEALTH OFFICE)
Date of undertaking Undertaker's full name
Undertaker's Address (in full)
Ship's name
Serial No.
SCHEDULE A. ...[88. 4, 5, 7, 11, 87.]
Serial No.
Slip No.
Undertaking to submit to surveillance.
of
being desirous of proceeding to
(which I hereby declare to be my full and sufficient address), hereby undertake, in consideration of my being exempted from quarantine, (to present myself for examination at the office of the situated at
daily at a.m. for days from the date hereof, and to report immediately at the said office any change in my residence) or (to proceed direct to the said premises and to submit myself for examination daily by the examinating officer for ...days from the date hereof).
I am aware that failure to comply with the terms of this under- taking, will render me liable to arrest, and, upon conviction, to a fine not exceeding $200.00 for every day during which the offence shall continue.
Dated this
Before me,
day of
Signature of Passenger.
Health Officer.
19
(TO BE HANDED TO UNDERTAKER)
Date of undertaking
Undertaker's name
Undertaker's address
Ship's name
Address of the
Period for which examination
is ordered
NOTE:Breach of this undertaking renders the offender liable to arrest and to a fine of not exceeding $200 for every day during which the offence shall
continue.
+
-41
To be printed at the back,
INSTRUCTIONS.
1. This undertaking is to be forwarded by the Health Officer to the
Health Officer of the area containing the Undertaker's address.
The slip is to be handed to the undertaker.
2. The Health Officer of such area will every day, as he visits the
undertaker initial the space below.
First day
Second day
Third day
Date.
Initials.
333