225553-1936-Ordinances-passed-and-assented-to--Def — Page 49

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THE HONG KONG GOVERNMENT GAZETTE, JANUARY 31, 1936.

Serial No.

(FOR RECORD IN THE

HEALTH OFFICE)

Date of undertaking

Full name of person undertaking

Address in full

Ship's name

SCHEDULE.

[s.s. 4, 5, 7, 10, 84.]

Serial No.

Slip No.

QUARANTINE AND PREVENTION OF DISEASE

Serial No.

I,

ORDINANCE, 1936.

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 observation, (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

Before me,

Health Officer.

19

Signature of Passenger.

(TO BE HANDED TO PERSON GIVING THE UNDERTAKING)

Date of undertaking

Full name of person undertaking

Address in full

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.