Reverse

I declare that the above particulars are true and correctly stated. I apply for leave to clear the above potable liquor for the purpose stated in column 17 above.

Plae:
Date:

(Signature of the licensee or his authorised agent)

The Manufactory Officer,

(Please see reverse)

Reverse

Certified that the particulars given in the Application No. of 19 , on the reverse of this have been verified and found correct. The consignment(s) as detailed in the application have been permitted to be cleared from the Manufactory and allowed to be exported/transported to under Export Pass No. Transport Pass No dated Issued by

Manufactory Officer.