250

THE NEW ZEALAND GAZETTE.

[No. 11

forth the facts and circumstances of such loss or destruc-
tion, and such declaration shall be filed in the office of the
Commissioner.

18. The forms set forth in the Schedule hereto are hereby
    prescribed as forms to be used for the purposes of the said
    Act and these Regulations.

SCHEDULE.

FORM A.

Form of Application for License as an Infants' Home Keeper
under "The Infant Life Protection Act, 1896" (Sections
5 and 6).

No.

I, the undersigned, apply for a license as an infants' home
keeper under "The Infant Life Protection Act, 1896," as
the occupier of the house the description of which is here-
under set forth, and I request that such house may be
registered as an infants' home under and for the purposes
of the said Act.*

And I declare that the several particulars above set forth
are true and correct, and that the same form the basis of
the application hereby made.

Dated this day of , 189 .

Witness to signature: (Signature of applicant.)

*[If application be for a renewal, add here: "I hold a
license under the said Act, which expires on the 31st day of
December, 189 , and which I desire to have renewed."]

The Commissioner of Police, Wellington.

FORM B.

Form of Home Keeper's License under "The Infant Life
Protection Act, 1896" (Section 8).

No. .

In pursuance of the provisions of "The Infant Life Protec-
tion Act, 1896," I hereby certify that [Name in full], of
[Residence and occupation], is duly licensed as the occupier
of [State situation of house], and that such house is duly
registered as an infants' home under the said Act.

This certificate entitles the holder to retain or receive
into care or charge in the above house
infants under the age of four years, and is in force until the
31st day of December, 189 .

Dated at Wellington, this day of , 189 .
, Commissioner of Police.

FORM C.—(Section 9 of Act.)

Register of Persons having Infants under the Age of Four
Years in their Care for Payment or Reward under "The
Infant Life Protection Act, 1896."

FORM D.—(Section 13 of Act.)

Record of Infants received into the Infants' Home at
, in Charge of

No. .

Date of entry into home :

Name of infant in full :

Sex :

Age :

Full names of parents (or guardians):*

Occupation of parents (or guardians):*

Address of parents (or guardians):*

Amount paid or to be paid to licensee in respect of infant :

In case of death, date and circumstances :

Removal : Date, name, occupation, and address of person
by whom removed :

• Strike out one or other, as the case may be.

FORM E.—(Section 16 of Act.)

Warrant for the Removal of a Child under "The Infant
Life Protection Act, 1896."

No. .

WHEREAS is now an inmate of , a licensed
infants' home within the meaning of "The Infant Life
Protection Act, 1896"; and whereas it has been made to
appear to my satisfaction that is entitled to remove
the said , and that the entry relating thereto in the
record-book is duly made and signed: I, , Inspector
of Police for the District of , do hereby authorise
such removal.

Given under my hand, at , this day of
, 189 .
, Inspector of Police for the District of .

FORM F.—(Section 18 of Act.)

Notice of Cancellation of License under "The Infant Life
Protection Act, 1896."

WHEREAS it has been made to appear to me that ,
licensee, is not conducting the infants' home for which she
holds a license in a satisfactory manner, and is therefore not
a fit person to hold such license: I hereby give notice that—
subject to appeal as provided in sections 19 et seq. of the
above-mentioned Act—the said license will be cancelled at
the expiration of ten days from the service of this notice.

Dated at , this day of , 189 .
, Commissioner of Police.

FORM G.

"Infant Life Protection Act, 1896" (Section 26).

Warrant for Custody of Infants when License is cancelled.

WHEREAS by virtue of the provisions of "The Infant Life
Protection Act, 1896," the license No. , dated
, granted to , has been cancelled: I hereby
order and direct the following infants now in the said
home shall be removed therefrom, and disposed of as
follows:—

Dated at , this day of , 189 .
, Commissioner of Police.

FORM H.

Certified Copy of Entry in Register of Persons licensed under
"The Infant Life Protection Act, 1896" (Section 37).

Register of Persons having Infants under the Age of Four
Years in their Care for Payment or Reward under "The
Infant Life Protection Act, 1896."

I certify that the above is a true copy of an entry in the
register of persons licensed under "The Infant Life Protec-
tion Act, 1896."

Dated at , this day of , 189 .
, Commissioner of Police.

FORM I.—(Section 4 of Act.)

Warrant of Exemption from Provisions of "The Infant
Life Protection Act, 1896."

In the matter of the application made by ,
of .

In pursuance of the powers conferred upon me by "The
Infant Life Protection Act, 1896," *[and upon reading the

• Omit this if no order by a Justice be made.