FORM CERTIFICATE I

: Bom. XXV] Bombay Prohibition Act, 1949 FORM CERTIFICATE I [See rule 15(3)] No. ........................................... Dated ....................................... Certified that Shri/Smt. /Kumari/Messrs. ........................................................................ of ................................. ............................................................ who has/have been granted an import Pass No. ................................... dated ...................................... by ............................... has/have been issued country liquor from the Distillery at ................................................. in the district of ................................... as shown below : ———————————————————————————————————— Description of No. of description of Marks and No. onCapacity of each Country Liquor each kind of sealed sealed package or sealed receptacle receptacle or packages receptacles or packages. (1) (2) (3) (4) ———————————————————————————————————— ———————————————————————————————————— ———————————————————————————————————— Actual contents Thermometer Hydrometer Strength Proof Litres Litres indication indication (5) (6) (7) (8) (9) ———————————————————————————————————— ———————————————————————————————————— and that receptacles and packages containing the said country liquor are securely packed in my presence and sealed with my official seal. Seal ............................................... Signature and designation of the Inspecting or Excise Officer at the place of Export. Place ....................................