FORM C. I. W. IV

: Bom. XXV] Bombay Prohibition Act, 1949 FORM C. I. W. IV (See rule 14) Application for pass to import duty paid country liquor Place ....................... Date ........................ To, The Collector, District .................................................................................................... Sir, I/We .............................................................................................................................. of ........................................................................................................................................................... (full address) request you to grant me/us a pass for the import of the undermentioned kind and quantity of duty paid country liquor from the Distillery situated at ...................................................... in the District of ............................................... in the state of ................................................. to my/ our wholesale licensed premises ....................................................... No situated at. in Greatcr Bombay * . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .in the District of ............................................................................................ on payment of duty in the State of Maharashtra. I/We furnish the requisite information as follows, namely : (1)Route by which Country Liquor is to be imported ........................ (2)Name address of my/our agent, if any, at the place ....................... (3)Purpose for which country liquor is to be imported ........................ ............................................................................................................................................................. (4)Period of validity of the pass required ........................................................................ 1 /we agree to abide by the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made thereunder and the conditions on which the pass may be issued to me/us. Yours faithfully, (Signature of the applicant). * Strike off the words which are not applicable. 558 Bombay Prohibition Act, 1949 [1949 : Bom. XXV PART IV (REVERSE) Particulars of Country Liquor advised and received ————————————————————————————————————————————————————————————————————————————— Advised as shown in the certificate issued by the officer at the exporting place ————————————————————————————————————————————————————————— DescriptionNo. andMarks andRegisteredLitresThermometerHydrometerStrengthProof of liquordescription ofNo. of eachcapacity ofactualindication indicationlitres each kind ofreceptacleeach receptaclecontents receptacle oror package or package package (1) (2) (3) (4) (5) (6) (7) (8) (9) ————————————————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————————————————— ReceivedLoss in transit ——————————————————————————————————————————————————————————————————— Litres actualThermometerHydrometerStrengthProofIncrease inFound P.AllowedExcess contentsindication indicationlitrestransitLitresP. LitresP. Litres (10) (11) (12) (13) (14) (15) (16) (17) (18) ————————————————————————————————————————————————————————————————————————————— ————————————————————————————————————————————————————————————————————————————— The consignment has been examined by me and I have found that the amount of duty and transport fee recovered from him is correct/less by ........................... As the importer has paid the difference in duty and fees recoverable from him and has agreed in writing to pay any excess amount of duty of fees that may be found to be due from him after receipt of the analysis report, I have allowed him to remove the consignment. (Signed) ....................................... Examining Officer.