Licence number of the transporter.
Quantity and Description of country liquor.
Quantity in scaled bottles 1[or containers]1
| Kind of country liquor |
In bulk litres |
No. of casks or 2bottles]2 |
No. of casks or drums |
750 ml. bottles |
375 ml. bottles |
180 ml. bottles |
| Country liquor 25 U.P. |
.. |
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| Country liquor 40 U.P. |
.. |
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Route ..
Name and Address of the person holding a wholesale licence
Number and Date of the indent in Form C.L. XXI by the person holding a licensed Retail shop.
Date upto which the pass shall be valid.
This pass is granted under and subject to the provisions of the Bombay Prohibition Act, 1949 and the rules made there under authorising the above mentioned transport, subject to the following conditions, namely:
The consignment shall not be broken in transit.
Dated: 12
Signature of the Wholesale Licensee.