582388-1940-Dentists-Regulations-1940 — Page 5

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THE HONG KONG GOVERNMENT GAZETTE, JULY 5, 1940.

FORM NO. 4.

I,

Registration of Dentists Ordinance, 1940. -

Application for Registration

under

Section 7 D.

) of

hereby apply for registration as a Dentist.

I solemnly and sincerely declare that I have been engaged as my principal means of livelihood in the practice of Dentistry in the Colony up to the date of the commencement of the above Ordinance for a period of

years at the following address or addresses:

I make this solemn Declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act 1885.

DECLARED at Hong Kong this

19 through the inter-

day of pretation of

the said

of

having been also first declared and he had truly distinctly and audibly interpreted the contents of this declaration to the applicant and that he would truly and faithfully interpret the declaration about to be administered to him.

Before me.

Justice of the Pence or Notary Public Hong Kong.

I.

do solemnly sincerely and truly declare that I well understand the English and Chinese languages and that I have truly distinctly and audibly inter- preted the contents of this declaration to the Applicant and I will truly and faithfully interpret the Declaration about

to be administered to him.

DECLARED at Hong Kong this

day of

19

Before me,

Justice of the Peace or Notary Public

Hồng Kong.

Photograph (passport size)

I the undersigned Justice of the Peace of the Colony of Hong Kong certify that the photograph attached to this application is a true photograph of the above named applicant

(

) who is known to me and whom I certify to be of good character and a it and proper person to be registered as a Dentist.

Justice of the Peace.

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