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The [1]
SECOND SCHEDULE.
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Sects. 4
,
6
,
10
.
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Form No. 1.
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Application for License of Retreat.
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The Habitual Drunkards Act, 1879.
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To the justices of the peace for the county [or borough] of [
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[or as the case may be].
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I, the undersigned, hereby apply for a license for the house described below, as a retreat for the reception of male [or female, or male and female] persons being habitual drunkards within the meaning of the above-mentioned Act, to be detained and treated as patients therein.
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And I, the undersigned, undertake to reside in the house and give my personal attention to the management, care, and treatment of the patients.
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Witness
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(Signed)
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Name ____________
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Name ____________
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Address ____________
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Address ____________
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Description ____________
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Description ____________
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[House to be described with the following (among other) particulars; and a plan on a scale of not less than one-eighth of an inch to a foot to accompany the description and be referred to therein:—
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a. Dimensions of every room.
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b. Arrangements for separation of sexes.
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c. Quantity of land available for exercise and recreation of patients.
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d. Extent of applicant’s interest in the house].
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Rules.
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1. An application may include two or more houses belonging to the same person or persons, provided no one of the houses is separated from another or others of them otherwise than by land in the same occupation and by a road, or in either of those modes.
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2. The application is to be made not less than ten days before the sessions or meeting at which it is to be considered.
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3. The clerk of the local authority is to give notice of the application having been made, by advertisement published in a newspaper circulating in the district of the local authority six days at least before the same sessions or meeting.
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Form No. II.
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License.
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The Habitual Drunkards Act, 1879.
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County [or borough] of
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This is to certify that in pursuance of the abovementioned Act the justices of the peace acting in and for the county [or borough] of [or as the case may be], in
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general or quarter (or special) sessions assembled, upon the application of A.B., a copy of which application is indorsed on this license, have licensed and do hereby license the said A.B. to use the house described in that application for the reception of persons being habitual drunkards, as follows; namely, male [or female, or male and female] patients for from this date.
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Dated this day of 18
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(Signed) __________________
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Clerk of the Local Authority.
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Rules.
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1. A fee of ten shillings is to be paid for the license.
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2. The clerk of the local authority, within ten days after a license has been granted, is to give notice of the granting thereof by advertisement published in a newspaper circulating in the district of the local authority and is to send a copy of the license to the Secretary of State.
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Form No. III.
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Request for Reception into Retreat
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The Habitual Drunkards Act, 1879
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To
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I, the undersigned, hereby request you to receive me as a patient in your retreat at in accordance with the above-mentioned Act, and I undertake to remain therein for at least, unless sooner duly discharged, and to conform to the regulations for the time being in force in the retreat.
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The above named signed this application in our presence, and at the time of his [or her] so doing we satisfied ourselves that he [or she] was an habitual drunkard within the meaning of the Habitual Drunkards Act, 1879, and stated to him [or her] the effect of this application, and of his [or her] reception into the retreat, and he [or she] appeared perfectly to understand the same.
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Dated this day of .
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Justices of the Peace for the county [or borough] of
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Witness’s
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Applicant’s
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Name in full.
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Name in full.
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Address.
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Address.
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Description.
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Description.
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[1 See note 2 to s. 6.] |
