3

E.—lo

And I make this solemn declaration conscientiously believing the same to be true, and by virtue of the Justices of the Peace Act, 1908. [Signature.] Declared at , this day of , 191 , before me — , Justice of the Peace [or Solicitor, or Notary Public]. [Here affix and cancel a stamp at 2s. 6d.] [Note. —The words relating to last year's subsidy and to free admission may be struck out if they are not applicable. The words in brackets are not part of the form, but indicate matter to be inserted or substituted. Copies of the form of application may be obtained from the Secretary for Education, Wellington, and from the Secretary of any Education Board. Thos. Mackenzie, Acting Minister of Education.