FORM C. L. XXI
Intendent the supply of country liquor to retail shop
See rule 31(2)
FORM C. L. XXI
[See rule 31(2)]
Original
Duplicate
Triplicate
Intendent the supply of country liquor to retail shop
- Name of the licensee................................................Indent No. .............................
- Location of the shop .............................................Date ......................................
- Licence No. ..............................................
To,
The Country Liquor Wholesale Licensee
..........................................................
..........................................................
Sir,
Please supply ........................................................bulk litres of country liquor in the Following receptacles :—
| Serial No. | Variety of country liquor | Strength | No. of bottles and other receptacles | |||||
|---|---|---|---|---|---|---|---|---|
| (1) | (2) | (3) | 750 ml. (4) | 375 ml. (5) | 180 ml. (6) | 200 B.L. (7) | * B.L. (8) | * B.L. (9) |
Total No.
Quantity in Bulk Litres
Signature of the Retail Sale Shop
Licensee or his Authorised Agent.
FORM C.L. XXI — contd.
The following quantity against the above indent has been issued under Transport Pass No. _______________________ dated the _______________________
| Serial No. | Variety of country liquor | No. of bottles and other receptacles | ||||||
|---|---|---|---|---|---|---|---|---|
| (1) | (2) | Strength (3) | 750 ml. (4) | 375 ml. (5) | 180 ml. (6) | 200 B.L. (7) | * B.L. (8) | * B.L. (9) |
Total No. _______________________
Quantity in Bulk Litres _______________________
Dated _______________________
Signature of the Wholesale Licensee or his Authorised Agent.
_______________________
* Here mention the bottles or receptacles of any other capacity allowed to be filled in by the '[Commissioner.]
Note
- Original of this is to be kept by the indenting licensee.
- Duplicate and Triplicate to be sent to Wholesale Licensee.
- The Wholesale licensee to fill in both the copies and return duplicate to the Retail Sale Shop Licensee and retain Triplicate on his record.
1 Added by G. N. of 20-6-1977.