ALL THE QUESTIONS MUST BE FULLY ANSWERED, OR THE APPLICATION WILL NOT BE CONSIDERED.
PRELIMINARY FORM.
THE ROYAL HOSPITAL FOR INCURABLES,
315
616/1915
Offices:
SIR, or MADAM,
PUTNEY HEATH.
4. ST. PAUL'S CHURCHYARD, PEC
LONDON, E.C.
58
C.O 43145
Aro 17 SEP 15
167
14 Sept 19 15
In reply to an inquiry received, I am sending this Preliminary Form, which I shall be glad if you will kindly fill in with clear and direct answers to the following questions with a view to securing the nomination of a candidate for election to the benefits of this Institution. The benefits of the Royal Hospital for Incurables are intended for the poorer middle classes.
The half-yearly Elections are held on the last Fridays of May and November. By the votes of Subscribers persons are elected, either as Inmates of the Hospital at Putney Heath, or as Pensioners who remain in their own homes and receive £20 a year.
I.
Full Name and Address.
2. Single or Married?
3. Age last birthday
(Cases under 30 years of age are not eligible).
4. Disease or Disability.
Where born,
5-
Social bosition, or previous occupation.
6. How maintained at present ?
7.
Has Parish Relief ever been received ?
8.
Are parents living ?
9. Means of parents, if living, or late occupation, if deceased.
IO.
Other near relatives.
ET.
Income of these relatwes.
12.
Number in families of these relatives.
13. Is admission, or pension sought ?
14.
Total of all sources of present income.
Upon hearing from you, and should the case be eligible according to the Rules (a copy of which is enclosed), the necessary papers for submission to the Board, will be forwarded. The applications are very numerous; the Board are only able to select a small proportion of the cases submitted to them.
Yours faithfully,
Et Rest, Exffice
Colonial
Downing
Street
t
CHARLES CUTTING,
Secretary.
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