CO129-545-9 Proposed reorganisation of medical and sanitary services 2-11-1933 - 10-1-1934 — Page 99

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— 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.

...[86. 4, 5, 7, 11, 87.]

Serial No.

Slip No.

Undertaking to submit to surveillance.

of

being desirous of proceeding to

a.m. for

(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 days from the date hereof, and to report inmediately ut 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

day of

Signature of Passenger.

Before me,

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.

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