FORM A

FORM A

(See rule 3)

Certificate by a registered medical practitioner showing whether a person examined by him has or has not consumed an intoxicant

Serial No. ______

(Name and location of the Dispensary or Hospital)

Certified that Shri/Smt./Kumari ______ of ______ was brought to this hospital/dispensary by ______ (here state name and designation of the Officer) on ______ 20 ______ at ______ a.m./p.m. and was examined by me on ______ 20 ______ at ______ a.m./p.m.

A clinical examination of the above-named person disclosed the following:

Additional remarks, if any: ______

I find that the above-named person has consumed alcohol / opium / charas / ganja / bhang
has not consumed any intoxicant.

I also find that he is under the influence of alcohol
is not.

N.B. — (Blood from the body of the above named ______ was collected by me for chemical examination). ______ was not.

Dated ______ 20 ______                                        (Signature)

Designation ______

Signature/Thumb-impression of the person examined ______

Marks of identification of the person examined in case he refuses to give his signature or thumb-impression.