FORM A

3431949 : Bom. XXV]	Bombay Prohibition Act, 1949
FORM  A
Form of Declaration
I, ............................................................................................... (Name of the importer or manufacturer), of ..........................................................	..... his
address ..................................................................................................................................... hereby declare that I have *imported on *manufacturer on
......................................................................................... (Please state here the date, month and year) the following articles mentioned in section 24.A of
the Bombay Prohibition Act, 1949, which the State Government have determined under section 6-A of the said Act to be unit for use as
intoxicating liquor and that they are in  my possession at present :-
Whether excise duty orName of Treasury inEvidence to show that
Serial No.Name of theQuantity Quantitycounter-valing duty, ifAmount ofRate atwhich duty is paid andduty has been paid
articleimportedmanufacturany, has been paid onduty paidwhich dutythe date of paymenttogether with
edthe articlepaidcorresponding chalan,
receipt or pass
(1) (2) (3) (4) (5) (6) (7) (8) (9)
Rs. a.p Rs. a.p
Date :
Place :
To,
The collector ofSignature of the importer or manufacturer
*Strike off which is inapplicable.