(iii) Whether the applicant was holding or was granted a licence in Form CL. III for the retail sale of country liquor but was not operating it on 1st January, 1979 and if so, reason (s) therefor.
I/We hereby declare that the particulars given above are correct.
N. B. : Wilful submission of false information or mis-representation of facts will render the licence, if eventually granted liable for cancellation under section 54 (1) of the Bombay Prohibition Act, 1949.
I /We enclose a chalan No date evidencing payment of a sum of Rupees (Rupees .) for the application.
I hereby undertake to abide by the conditions of the licence and the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under from time to time.
Date .......... ..... Signature of the applicant