FORM F. L./M.C-D1

788	Bombay Prohibition Act, 1949 [1949 : Bom. XXV
(3)Age and date of birth. .................................................................................
(4)Particulars of proof of age. .................................................................................
produced with the application
(5)Occupation . .................................................................................
* I hereby declare that I require mild liquor for the preservation and maintenance of my
health.
I sumbit herewith the medical certificate in Form  F. L. M. C.-2 signed by Dr. ...................
...................Registered Medical Practitioner, in support of my application.
I hereby undertake to abide by the conditions of the permit and the provisions of the
Bombay Prohibition Act, 1949 and rules, regulations and orders made thereunder.
Place :
Date :	Signature or thumb impression
of the applicant.
To,
The Collector of ................................
(or authorised Officer).
*[for applicants in Wardha District only].
-------------------------
1
[FORM F.   L./M.C-D1
2
[(See rule 70-D)]
Application Form  F. L./A-6D No. ...............................................................................................
Certificate of a Registered Medical Practitioner/Government Medical Officer
recommending the grant of permit to possess and use foreign liquor
and country liquor for personal consumption.
This is to certify that Shri/Smt./Kum. ................................................................................ of
...................................................... by his/her statement aged .....................................................
years and is apparently about ............................................. years of age and that he/she
requires foreign liquor and/or country liquor for the preservation and maintenance of
his/her health.The grant of the permit to him/her is recommended.
Signature or thumb impression
of the applicant .........................................
Full address of the applicant :
Signature of the Registered Medical
Practitioner and his name and
Station	registration number.
Date :	Signature and Designation of a Govern-
ment Medical Officer and his name.]
1.Ins. by G. N. of 8-8-1979.	2.Subs. by G. N. of 4-5-1982.