FORM F. L. /A-5

FORM F.L./A-5

[See rule 69(2)]

Application No. _____________

Application for a Visitor's Permit to possess and use Foreign Liquor for personal consumption

1. Name in full (surname first in BLOCK letters). _____________________________________________
2. Permanent address . . _____________________________________________
3. Temporary address in the '[State of Maharashtra]. _____________________________________________
4. Date of arrival in the State of Maharashtra. _____________________________________________
5. From where arrived and by which train/boat/ari service. _____________________________________________
6. Period of temporary stay in the '[State of Maharashtra]. _____________________________________________
7. Proposed date of departure and place to which proceeding. _____________________________________________
8. Dates and duration's of previous visits to '[Maharashtra State] during the last twelve months. _____________________________________________
9. Nationality. _____________________________________________
10. State/Country of domicile. _____________________________________________
11. Age . . _____________
12. Occupation _____________________________________________
13. Quantity of foreign liquor required _____________________________________________
14. Period for which the permit is required. _____________________________________________
15. If there is Prohibition in the State/ Country where the applicant resides, he should state whether he holds there any permit to possess and consume foreign liquor, the nature of permit and the monthly quantity of foreign liquor allowed thereunder. _____________________________________________

¹ Subs by G. N. of 25-7-1963.

I hereby declare that—

1. (a) I intend to reside in the State of Maharashtra for a temporary period only and that i am only a visitor to the 'State of Maharashtra'.
2. (b) I am ordinarily using and consuming foreign liquor ;
3. (c) I do not hold any permit under section 40, 40-A, 41, 46, or 47 of the Act nor have I made any other application for a permit under any of these sections;
4. (d) the particulars given above are correct.

I hereby undertake—

1. (i) 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;
2. (ii) to furnish such information or proof in support of my declaration as may be required now or hereafter.

Date ___________

Signature of the applicant.

To
The Collector of ___________
The Prohibition and Excise/Police/Customs Officer.

(Not to be filled in by the applicant)

Date of application ___________
Permit prepared by ___________
and issued on ___________

Received the permit No. ___________ on ___________

Signature of the applicant.

Signature of the officer
issuing the permit.

¹ Subs by G. N. of 25-7-1963.