FORM F. L. /A-3

FORM F.L./A-3

[See rule 67(1)]

Application No. ___________

Application for a permit to possess foreign Liquor for medicinal use on emergent occasions

1. Name in full Shri/Smt./Kumari ___________
   (Surname first in BLOCK letters)
2. Residential address in full ___________
3. Nationality ___________
4. Religion ___________
5. Age ___________
6. Occupation ___________
7. Monthly Income ___________
8. Kind of liquor required ___________
9. Whether the applicant is head of household I declare that —
   1. I usually keep *___________ for medicinal use.
   2. I have at present got stock of *___________ as under:
      (Here state the stock)
   3. Neither I nor member of my house hold holds any Emergency Permit nor have I or any member of my household has applied for any such permit.
   4. [(cc) I have +/have not been convicted on (date) +/ at any time of an +/any offence punishable under sections +/any provisions of the Bombay Prohibition Act, 1949.
      
      There is a +/is no prosecution under sections +/any provisions of the said Act pending against me in the +/any Court in Maharashtra State.]
   5. The particulars given above are correct.

I hereby undertake to abide by the conditions of the permit and the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made thereunder.

To,

The Collector of ___________ District.

* Here entername of liquor.
+ Strike out whatever not applicable.
1. Ins. by G. N. of 17.5.1955.

Form of Receipt

S. No.

Received from

_____________________
_____________________
an application for an emergency permit for liquor.

Dated _____________________

Signature of the officer receiving
the application.

The applicant is requested to present personally this receipt, on _____________________

FORM F.L./A-3

(or Office use only)

Signature of the Applicant.

Seen.

Signature of the permit-issuing authority.

Filed.

Name and address in full to be filled by the applicant.