1964_DRUG_ADDICTS_TREATMENT_AND_REHABILITATION_REGULATIONS — Page 6

A6

[Subsidiary]

CAP.326]

Drug Addicts Treatment and

Rehabilitation Regulations

[1972 Ed.

Dated this

day of

19.........

日期: 一九

年

月

日

Signed by the said

本申請書由該

in the presence of-

在

面前簽署。

(Signature of Applicant).

(申請人簽署)

The Hong Kong Government or such other person as may be entitled thereto.

* 請填香港政府或有權收費之其他人士。

FORM 3

表格三

[r. 3.]

(規則第三款)

Drug AddicTS TREATMENT AND REHABILITATION ORDINANCE 戒毒人治療與康復條例

(Chapter 326)

(香港法例第三二六章)

Bond to pay Cost of Treatment

趱付洽擦費保證書

BY THIS BOND I

本人

(Name in English).

(英文姓名)

..) of

(Name in Chinese Characters, if any).

(Address).

(.........

.) 現居

(中文姓名)

(地址)

acknowledge myself bound to

茲根據上這條例第十 一款之規定,以本保

in accordance with the provisions of section 11 of the Drug Addicts Treatment 證書向*

and Rehabilitation Ordinance, in the sum of $..

(........

(港幣

保證,繳交$

Hong Kong Dollars)

元)

to be paid to the said

*

Sealed with my seal this

day of...

19

本保證書由本人於一九

年

月

日蓋印。

NOW THE ABOVE WRITTEN BOND is conditioned to be void in

上述

case the above-bounden

保證人

his

, 其

personal representative or any person acting for or on behalf of him shall 代表人由接 接獲合法之繳款耍時起 within one month of the lawful demand therefor, from time to time, pay

個月內 將所有應 趱 款項 項交與 *

j

i

!