FORM CERTIFICATE I
[See rule 15(3)]
Dated..............................................
Certified that Shri/Smt. Kumari/Messrs ................of .............................................. who has/have been granted an import Pass No. ..................dated .......................................... by... has/have been issued country liquor from the Distillery at ..................in the district of .......................................... as shown below:
| Description of Country Liquor (1) | No. of description of each kind of sealed receptacle or packages (2) | Marks and No. on sealed package or receptacles (3) | Capacity of each sealed receptacle or packages. (4) |
|---|---|---|---|
| Actual contents Litres (5) | Thermometer indication (6) | Hydrometer indication (7) | Strength (8) | Proof Litres (9) |
|---|---|---|---|---|
in my presence and sealed with my official seal.
Seal
Signature and designation of the Inspecting or Excise Officer at the place of Export.
Place
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