FORM CERTIFICATE 4

Bombay Prohibition Act, 1949 [1949 : Bom. XXV FORM “CERTIFICATE-4” [See rule 29] No. ............................. Date ........................... Certified that Mr./Mrs./Miss/Messers. ........................................................................................ who has/have been granted an export pass No. ............................................................... dated ...................................... by ................................................... has/have delivered the duty-paid imported foreign liquor as shown below on ......................................... to .................................... of ...................................................... in the district of .............................................. in the state of ..................................................... —————————————————— ——————————————————— Kind of Indian-made Number of Quantity delivered foreign liquor packages or Litres Strength Proof Remarks Duty-paid imported foreign liquor receptacles litres ———————————————————————————————————————————— ———————————————————————————————————————————— and that the seals on the packages and receptacles containing the above foreign liquor were intact at the time of delivery of the consignment at its destination. Signature and designation of the Excise Officer at the importing place. Place :