NAME ..................... NO.............................
ADDRESS...................................................
WHEN BORN AND WHY ?......................

1. I hereby make application to be ill. (Permit.)
2. I declare:

A) That I have a pain in my (i) head (ii) stomach (iii) chest (iv) arms (v) ........
B) That my complexion is (i) ruddy (ii) pallid (iii) green.
C) That I have broken my (i) arm (ii) leg (iii) back (iv) engagement
D) That during the past 12 hours I have been sick ...... times
E) That I expect to be sick again in .... Hours.
F) That I am afraid I shall (i) die (ii) not die (iii) live (iv) not live
G) That I am off my (i) food (ii) drink (iii) head.

3. The name of my Doctor is .............
4. The name of my Veterinary Surgeon is ............
5. I have been taking (i) salts (ii) pills (iii) tablets (iv) liberties
6. I am in (i) bed (ii) pain (iii) desperation (iv) my coffin
7. What is the effect of a dose of Cascara ......... A) how many times .........
8. I can see (i) spots (ii) nothing (iii) animals. If animals, state what type and colour ..........
9. I have spots on my .......... A) They do / do not / itch B) I am / am not / scratching them.
10. I am / am not pregnant. (In case male patients, further details should be given on a separate sheet. Blankets should not be used.)
11. I am (i) depressed (ii) elated (iii) about to shoot myself.
(Note: in this case a Firearms Licence is required.) 12. I would be willing to take (i) medicine (ii) treatment (iii) medicine and treatment (iv) treatment and medicine (v) poison. (State preference, and whether fast or slow.) 13. I request admission to (i) hospital (ii) asylum (iii) mortuary.
14. I request the services of a (i) doctor (ii) midwife (iii) nurse.
15. I believe my complaint to be .......... In case a permit cannot be issued for this complaint would you be willing to accept another illness, malady or disease? State Yes or No.

This form when completed should be submitted, in triplicate, to the local Health Officer. Should the applicant die before the permit is issued the Local Health Officer should be notified and a new application for a permit to be declared dead (Form R.I.P) should be submitted by a relative or creditor.

Permits are not transferable, but a permit for a common cold may be used by all members of an applicant's family, provided that all the colds up to a maximum of six, are caught within 14 days of the date of issue.

Declaration.
I declare that all the above answers are as true as those on my petrol application.

Signature:
Date:

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