SCHEDULE

(Section 7.)

FORM OF CERTIFICATE

To                                   , the undersigned,                                  do hereby certify that I received on the                           day of                           19          , from              a sample labelled                       for analysis and I have analysed the same, and declare the result of my analysis to be as follows:-

I am of opinion that the same is a sample of genuine

or

I am of opinion that the said sample contained the part as under, or the percentages of foreign ingredients as under:-

Observations.

As witness my hand this                               day of                       at             .