FORM CL.XXV
[See conditions 5,11,13 and 7 of the licences in form C.L. I, C.L. II, C.L. III and L./F.L/H respectively]
Name of the Country Liquor Manufactory/Warehouse/Retail Sale Shop ...............
Account of samples of Country Liquor* / Material* taken for analysis
| Date of drawing sample | Name of Officer drawing sample | Variety of Country liquor / Material* | Batch No. | Quantity drawn | Quantity used for analysis | Quantity if any returned to the manufactory and mixed with the main bulk of Country liquor / Material* |
|---|---|---|---|---|---|---|
| (1) | (2) | (3) | (4) | (5) | (6) | (7) |
| Amount of analysis fee if any paid | Chalan No. and date | Here state the result of analysis when known | Initials of the sample drawing officer | Initials of the licensee or his authorised Agent | Remarks if any |
|---|---|---|---|---|---|
| (8) | (9) | (10) | (11) | (12) | (13) |
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