Authorisation
FORM B
See rule 4 (2)
What this form is for
Form B is a forwarding letter that accompanies a phial of venous blood sent to the Testing Officer for chemical examination, with a request to test it and issue a certificate in duplicate. It is completed by the registered medical practitioner who collected the blood from a person produced before them for medical examination or blood collection, typically in a suspected prohibition offence. The practitioner sends it by post or through a messenger along with the sealed phial. It is prescribed under rule 4(2) of the Bombay Prohibition (Medical Examination and Blood Test) Rules, 1959.
Form text (extracted)
994 Bombay Prohibition Act, 1949 [1949 : Bom. XXV
was
N. B.–– (Blood from the body of the above named ———— 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.
–––––––––
FORM ‘B’
[See rule 4 (2)]
No. . . . . . . . . . . . . . . . . . . . .
From
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name , designation and address of the registered medical practitioner.)
To,
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(Name , designation and address of the Testing Officer. )
Dated . . . . . . . . . . . . . . . . .20.
Sir,
I, forward herewith by post/with Shri* . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
of . . . . . . . . . . . . . . . . . . . . . . . a phial bearing serial No. . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .
containing. . . . . . . . . . . . . . c. c. o. venous blood collected by me on. . . . . . . . . . . . . . . . . . . .
at. . . . . . . . . . . . . . . . . . . . . . . . . . .a.m./p.m. of . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . who was
produced before me for medical examination †and/or collection of blood from his/her
body ‡ by . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . and request
you to test the blood and issue a certificate (in duplicate) regarding the result of the test.
Yours faithfully,
Signature and designation of the
registered medical practioner.
Facsimile of the seal or monogram used for
sealing the phial containing the blood.
* Here specify the name, designation and address of the messenger with whom the phial containing the
blood is forwarded for delivery to the Testing Officer.
† Strike off, if these words are not required.
‡ Here state the name and designation of the officer by whom the said person was produced for
collection of blood.
Original PDF (as scanned from printed manual)