1[FROM F.L.
/A-6-B]
[See rule 70-D (2)]
Application No.
Court Fee Stamp
Application
for a permit for the purchase, possession, transport use and consumption of
Foreign
Liquor and Country Liquor in the State of
Maharashtra
.
(1)
Name in full Shri /Smt. /
kum. ………………………………………..
(Surname first in BLOCK letters)
(2)
Residential address in full………………………………………………
(3)
Age and date of birth…………………………………………………..
(4)
Details f proof of age produced
with this application……………….
(5)
Occupation ……………………………………………………………
(6) 2*
*
*
*
*
*
*
3[I hereby declare that I require foreign liquor
and country liquor on grounds of health and in support of my application I submit
herewith the medical certificate inform F.L./M.C. 1 signed by Dr.……………………………………………………
Registered Medical Practitioner.]
I hereby undertake to
abide by the condition and the rules, regulations
and orders made thereunder of the permit and the
provisions of the
Bombay
Prohibition Act, 1949,
place:
Signature or thumb impression of
the applicant
Date:
To
The Collector of …………………..
(or authorized Officer).]