FORM NO. C.I.XII

(See Rules 3)

APPLICATION FOR LICENCE FOR IMPORT AND SALES BY WHOLESALE OF COUNTRY LIQUOR

Name or names and address or addresses of the person or person applying, if the applicant is a firm the name are address of every partner of the firm and if a company, the registered name and address there of, the names of the Directors, managers and Managing Agents, and if there is a managing Director, his name.
Location of the shop or premises where the applicant wants to sell imported Country Liquor with census number of the house or building, name of street, village, town or city, as the case may be.
Where the person or any partner of the firm or the Director, Managing Director, Manager or managing Agent of a Company is/was holding any Excise Licence, if so state the kind of licence held and the duration of the licence.

Whether any excisable articles are/were stored in the premises proposed for location of the licence and if so, give full details.

Certificate from the Municipality / Grampanchayat, etc. to the effect that it has no objection to locate the licenced premises in the concerned locality.

Does the applicant agree to give an undertaking in writing to abide by the provisions of the Act, and the rules, regulations and orders made there under and conditions of the licence applied for

Whether the applicant has been convicted at any time of an offence punishable under any of the provisions of the Bombay Prohibition Act, 1949, or any Rules, Regulations or Orders made there under.

I/ We hereby declare that the particulars given above are correct I/We enclose a Chalan No , and dated as an evidence for the payment of a sum of Rs. 25 (Rupees twenty five only) for the application.

I/We hereby undertake to abide by the conditions of the licence and the provision of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under from time to time.

Date ....................................................

Place .................................

Licensee.

Signature of the Applicant.

The Secretary to the Government of Maharashtra,
Home Department, Sachivalaya, Bombay
(though the Collector of )

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