FORM R.S. HI

(See rule 18)

Requisition for rectified spirit or absolute alcohol

Part IV

(To be sent to the Inspector of Prohibition and Excise in whose charge the licensed premises of a person holding a sale licence, warehouse or distillery is situated.

Place.

Date.

Mesa

— Warehouse —

The————————————— Officer,

Distillery

Sir(s),

Please supply me/us with litres/bottles of millilitres each] of rectified spirit / absolute alcohol for Purposes.

e . sale licence . ..

The number or my rectified spirit————————————————————— issued by

¹[possession licence/bottling licence.]¹

the Collector of.

Yours faithfully,

Signature of the purchaser

Countersigned.

Inspector of Prohibition and Excise Date No

Seal of the

Officer

Countersigning

The requisition.

Verified from the register of the supplying Licensee or the Warehouse/Distillery

Officer on

Intimation of the supply sent to the Prohibition and Excise Officer countersigning the requisition on .

Signature of the Inspector of

Prohibition and Excise.

Subs. by G.N. of 26-9-1966.