FORM C.I.W IV

District ..............................

Sir/Madam,

I/We .............................. of

(full address)

request you to grant me/us a pass for the import of the undermentioned kind and quantity of duty paid country liquor from the Distillery situated at .............................. in the District of .............................. in the State of .............................. to my/our wholesale licensed premises No .............................. situated at .............................. in Greater Bombay* in the District of .............................. on payment of duty in the State of Maharashtra.

I/We furnish the requisite information as follows, namely:

1. Route by which Country Liquor is to be imported .................................
2. Name address of my/our agent, if any at the place .................................
3. Purpose for which country liquor is to be imported .................................
4. Period of validity of the pass required .................................

I/we agree to abide by the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under and the conditions on which the pass may be issued to me/us.

Yours faithfully,

(Signature of the applicant).

* Strike off the words which are not applicable.