FORM F. L. /A-4

7711949 : Bom. XXV]	Bombay Prohibition Act, 1949
FORM  F.  L. /A-4
[See rules  68(1)]
Application for a special permit for privileged personages to possess
and use  foreign liquor for personal consumption
1.Name and address in full (surname first in BLOCK letters). .
2.Whether the applicant is—
* (a)a sovereign or Head of a Foreign State;
* (b)an Ambassador or Diplomatic envoy of a Foreign State;
* (c)a Consul, Honorary Consul or Trade, Commerce or other representative of a
Foreign State ; or
* (d)a member or the staff appointed by or serving under any person specified in
clause (a), (b) or (c) and whether such member is national of a Foreign State or
an Indian national; [Please state the official designation of the applicant and
the name of the Foreign State, in each case, i.e. (a), (b), (c) or (d),] or
1
[(d1)a member of a Foreign Government; or
*(d2)a representative or officer of an international organisation to which privileges
and immunities are given from time to time by or under the United Nations
(Privileges and Immunities) Act, 1947; or]
* (e)the consort of any person specified in clause (a), (b), (c), 
2
[(d), (d1) or (d2)]
(please state the name and official designation of such person); or
* (f)any relation of any person specified in clause (a), (b), (c), [(d1) or (d2)]
dependent upon him; and if so, what is the relationship and with whom (please
state the name and official designation of such person).
3.Nationality	. .
4.Religion	. .
5.Age	. .
6.Permanent address . .
7.Maximum number of units of foreign
liquor desired to be possesses at a
time.
8.Period for which the permit is required.
I hereby undertake to abide by the conditions of the permit and the provision of the
Bombay Prohibition Act, 1949, and the rules, regulations and orders made thereunder.
Signature of the applicant and
Dated	his designation.
*Please strike off the unrequired items or words.
1.Added by G. N. of 18.9.1961.
2.Subs, ibid.

772	Bombay Prohibition Act, 1949 [1949 : Bom. XXV
To,
The  Collector  of
(No fee is charged for this form)
Form of receipt
S. No.
Receivedfrom
of                  an application for a Foreign Liquor Special Permit for
privileged personages.
The permit will be ready on                                                    when it may be obtained from
this office on presentation of this receipt.
Signature
Dated	Designation
----------------------
(Reverse of the Application Form F.L./A-4)
Received the application on
Permit to be ready on
Permit prepared by	on
Permit checked by	on
Received permit No.	on
Signature of the Applicant.
Seen.
Filed.	Signature of the permit-issuing authority.