[See sub-rule (1) of rule 61] Application by the prisoner to the Superintendent of a Prison for release under section 2 of the Madhya Pradesh Prisoners' Release on Proabtion Act, 1954.

[To be supplied to a prisoner, his relative (or his), guardian free of charge] Application by the prisoner to the Superintendent of a Prison for release under section 2 of the Madhya Pradesh Prisoners' Release on Proabtion Act, 1954. (Act No. 15 of 1954) (To be filled in by the prisoner and his guardian) Jail. ........................ 1. Name and No. of Prisoner .................... . 2. Father's Name ............................. . 3. Caste ............................. . 4. Residence-Village, mohalla or town ................. . Police Station ................., District .................. . 5. Name of the proposed guardian with his father's name ........................................................ . 6. Guardian's caste .......................... . 7. Guardian's age ........................ . 8. Guardian's occupation ............................. . 9. Guardian's residence-Village, mohalla or town ................. . Police Station ................., District .................... . 10. Is the guardian literate ? ............................. . 11. Is the guardian related to the prisoner ? If so, how? ............................. . Declaration by the Prisoner I hereby, declare that I desire to be released on licence under the Madhya Pradesh Prisoners' Release on Probation Act, 1954, and shall faithfully comply with the conditions of the licence. Dated ................. . Signature of the Prisoner/Left thumb impression. Declaration by the Guardian I on behalf of .................... Institution/Society agree to undertake the supervision of ..................... prisoner mentioned above and shall comply with the provisions of the Madhya Pradesh Prisoners' Release on Probation Act 1954, the rules framed thereunder and the conditions of the licence. Dated .............. . Signature of the Guardian/Left thumb impression. (To be filled in by the Superintendent of Jail) Casual/Habitual No. of previous convictions, if any .................... . 1. Prisoner's Name and No ................................... . 2. Prisoner's age ............. years, offence ................. . 3. Sentencing Officer and Case No ........................ . 4. Period of sentence .................... fine, if any ............... . fine realised ....................... . 5. Date of sentence ............................................... . 6. Period actually spent in jail up to the date of application ........................ months .......................... . 7. Remissions earned ............... years ............... months ................................. days. 8. Total of columns 6 and 7 ............ years ...... months ........................... days. 9. Prisoner's date of release after allowing probable remission under the rule ...................................... . 10. Physical and mental condition of the prisoner *11. Conduct in Jail .............................................. . *12. Effect of imprisonment undergone ...................... . *13. Is the prisoner eligible in every way ? If not, the superintendent shall in his own hand record here the order rejecting this application with reasons ..... . †14. Is it advisable to release the prisoner on licence? Entries checked with warrants ........................... . Superintendent of Jail. Jailor. Date .................... Name of Jail. ......................... . (To be filled in by the District Magistrate) 1. Date of receipt in the District Magistrate's office ..... . 2. Brief History of the case ............................. . 3. Is the proposed guardian fit to act as such .............. . 4. Having regard to the prisoner's antecedents and his conduct in prison, is he likely to abstain from crime and lead a peaceable life if released on licence ? ..... . District Magistrate, Name of District. Recommendation of the Board 1. Recommended for release on licence ................. . 2. Recommended for release on licence after ............... months in default of payment of fine or sooner, if fine or portion of fine is paid. 3. Recommended for release on licence provided a suitable guardian is available. 4. Recommended for release on licence after .............. month if prisoner's conduct is satisfactory. 5. Postponed till ............ if prisoner's conduct is satisfactory. 6. Postponed till a suitable guardian is forthcoming ..... . 7. Rejected ........................................................... . 8. Name of guardian to be recognised .................... . Member. Member. Chairman. Dated ..................... 19. ORDER OF GOVERNMENT Board's recommendation accepted. Dated ..................... 19. Secretary to Government. Endorsement on revocation of licence. Dated ..................... 19. Secretary to Government.