221399-1935-Supplementary-Public-Heaith-Quarantine-and-Prevention-of-Disease- — Page 29

641

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 examination 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

Slip No.

(TO BE HANDED TO UNDERTAKER)

Date of undertaking

Undertaker's name

Undertaker's address

Ship's name

Address of the examining officer to whom the undertaker must report

Period for which examination

is ordered

NOTE:-Breach of this undertaking renders the offender liable to arrest and to a fine not exceeding $200 for every day during which the offence shall continue.

Serial No.

(FOR RECORD IN THE HEALTH OFFICE)

Serial No.

Date of undertaking Undertaker's full name

I,

Undertaker's Address (in full)

Ship's name