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 ofNo. of description ofMarks and No. onCapacity of each Country Liquoreach kind of sealedsealed package orsealed receptacle receptacle or packagesreceptacles or packages. (1) (2) (3) (4) ———————————————————————————————————— ———————————————————————————————————— ———————————————————————————————————— Actual contentsThermometerHydrometer StrengthProof 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 ....................................