town/village of district in the 1[State of Maharashtra]1 in accordance with the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under and the conditions of the licence issued there under and in case of my/our making default in the observance of the provisions of the said Act and the rules, regulations and orders made there under and the conditions of the said licence I/We bind myself/ourselves, jointly and severally and each and every one of my/our respective heirs, executors, administrators and representatives, to forfeit to the 1[Governor of Maharashtra]1 the sum of rupees ♦ in guarantee of which I have deposited with Government an amount of Rs in cash† in securities.
Place
Dated this day of 20
In the presence of—