FORM C

FORM C

See rule 5

Certificate of Result of Test of Sample Blood

Serial No. ______

Certified that the phial bearing serial No. ______ containing ______ c.c. of venous blood, sealed with the seal/monogram of Dr. ______ (Registered Medical Practitioner) and forwarded to me on ______ 20 ______, was received in this office on ______ 20 ______ in a sealed condition.

The blood sample was tested by me on ______ 20 ______ and the result of the test is as follows:

Alcohol content (by weight per 100 c.c. of blood): ______ per cent

Other findings (if any): ______

Note: Under section 129-A(6) of the Bombay Prohibition Act, 1949, if the alcohol content is not less than 0.05 per cent, weight in volume, the person shall be presumed to have consumed liquor for the purposes of the said Act.

Dated ______ 20 ______                                        Signature and designation of the Testing Officer.