FORM C.L. XXI
[See rule 31(2)]
Original
Duplicate
Triplicate
Indent for the supply of country liquor to retail shop
(1) Name of the licensee. .................. Indent No. ....................
(2) Location of the shop .................. Licence No. ....................
The Country Liquor Wholesale Licensee
Sir,
Please supply .................. bulk litres of country liquor in the following receptacles:
| Serial No. | Variety of country liquor | Strength | No. of bottles and other receptacles 750 ml. 375 ml. 180 ml. 200 B.L. B.L. B.L. |
|||||
|---|---|---|---|---|---|---|---|---|
| (1) | (2) | (3) | (4) | (5) | (6) | (7) | (8) | (9) |
| Total No. | ||||||||
| Quantity in Bulk Litres | ||||||||
Signature of the Retail Sale Shop Licensee or his Authorised Agent