NAME.

Form of Tabular Statement to be submitted by the Examiners.

NAME.

各

NAME.

VIII.

Second L. M. S.

Age.

Name and position of
father or guardian.

Race (i. e, nation, tribe,
&c.) and religion.

Town or village where
resident.

Date of passing the Pre-
liminary Scientific Ex-
amination.

College, Hospital, or Dis-
pensary, at which Can-
didate has studied since
passing the Preliminary
Scientific Examination.
Present position or occu-
pation.

X.

First M. B. & C. M.

Name and position of
father or guardian.
Race, (i. e., nation, tribe,
&c.) and religion.
Town or village where
resident.

Date of passing the F.A.
Examination.

Optional language in
which Candidate has
passed at the F. A.
Examination.

College, or Colleges, at
which Candidate has
studied Chemistry and
Botany.

Present position or occupation.

NAME.