FORM R.S. IV-A

[See rule 23 (1)]

Application for a pass for the transport (not incidental to purchase) of rectified spirit (including absolute alcohol)

Name and address of the applicant
Kind of licence held by the applicant and its numbers and date and by whom granted.

Quantity and description of rectified spirit to be transported.

Kind of spirit	²Proof liters²	²Dozen bottles each of 750 milliliters²	²Dozen bottles each of 500 milliliters²	²Dozen bottles each of 250 milliliters²
	(1)	(2)	(3)	(4)	(5)
Rectified Spirit
Absolute Alcohol

Place to which rectified spirit is to be transported.

Route.

Purpose for which rectified spirit is to be transported.

Name and address of the place from which rectified spirit is to be transported.

Kind of the licence held in respect of the Premises from which rectified spirit is to be transported and its No. and date.

Period within which rectified spirit will be transported

I request that a transport pass for the above quantity of rectified spirit may be issued to me.

I hereby undertake to abide by the conditions of the transport pass and the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and order made there under

Signature of the applicant

Place:

Date:

The Collector of ..........

Through the District Prohibition and Excise Officer ......................

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