1960-HKRS30-8-50_Part04 — Page 45

6

I/We lodged with the Director of Social Welfare on the

11.

of

渡劫蹀申請

-

九

19........

..... notice of my/our intention to apply

an Adoption Order in respect of the infant.

[12. A certificate as to physical and mental health of the infant, signed

by a registered medical practitioner on the

麵

19.

la attached.) (19)

登者](注)

13.

ANNEX TO Form 3. 第三海楼之附文

Further particudors of applicant or applicants.

-

獎,駡陵

日制

Name in full (Block capitals)

T/We have not received or agreed to receive, and no person he

made or given or agreed to make or give to me fus, any payment or other

reward in consideration of the adoption [except as follows:

[] ㄌㄌ回

14. I have not made/Neither of us has made a previous application for 人以前洋常向任何违路中 an Adoption Order in respect of the same or any other inland to any court [exosp 辭發於

新老会隙

an application made to the 热

辅

月

日向

court at

之申請

on the

19.......... which was dealt with as follows:

蒲蒲

Dus of Birth

出生日期

Particulars of CD,

關於

之各項

Relationship (18 any) to the infant

社

Particulars of E.D. 關於 之各骐

[15.

For the purposes of my/our application reference may be made to

Ju

签](註一)

Nume in full (Block capitals) 全啊(正職,

W.O.f 芯

[16. I/We desire that my/our identity should be kept confidential, and

the serial number of this application is

]

or [I/We do not desire that my/our identity should be kept confidential].

17. Further particulars of myself/ourselves are set out in the annex no

This sutement.

18.

(

If an adoption order is made in pursuance of my/our application. 如您

it is proposed that the infant should be known as

陛址

Thike of Birth

出生日期

Relationship (if any) to the infant

Dated this

day of

年

月

(Usual signature of applicant/applicants).

申請人或中缺人等常用之家)

Hen:

十

Crkger

This tabement must be verified by atidavit, to which the stateracnt, morriage certificate

and other document referted to in the statement should be exhibited.