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30
No............. Date of expiration of Milk Order.............................
Borongh of Hampstead
PUBLIC HEALTH DEPARTMENT.
Town Hall, Haverstock Hill,
Hampstead, N.W. 3.
MATERNITY AND CHILD WELFARE ACT, 1918.
Application Form for Milk at Reduced Rate.
Name of Applicant Married or Single..
Address
Rent Total Income of family from all sources
Occupation of breadwinner
Name and Address of Employer
Children (names and ages)
Pre-Maternity Clinic attended (if any)
Infant Welfare Centre attended (if any)
Name and Address of Milkman
Daily Consumption of Milk
REMARKS..................................................
Signature of Head of Family
(it is necessary that the husband, if at home, should sign this application.)
Please state if husband is living elsewhere.
Date 19
This Form when completed to be sent to the Medical Officer of Health
at the Town Hall.