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4. Whether the proposed premises referred to at item 3 above g-

(a) Within 50 meters from any educational or religious institution or monuments of National importance are within the jurisdiction of any Municipal Corporation or 'A' Class or 'B' Class Municipal Council and 100 meters if situated elsewhere.
(b) Within 50 meters from any Bus stand, station, or depot of the Maharashtra State Road Transport Corporation.
(c) Free from Highway restriction as per rules or time-to-time orders/instruction from the State Government.

I/We hereby declare that the particulars given above are correct.

I/We hereby enclose a Chalan No. ................. evidencing payment of a sum of Rupees .................... (Rupees .................................... in words) for the application.

I/We hereby undertake to abide by the conditions of the primary licence in Form F.L.II and the form of its upgradation and the provisions of Maharashtra Prohibition Act, and rules, regulation and orders made thereunder from time to time.

I/We hereby further undertake to surrender the primary licence in Form F.L.II with the form of upgradation provided under sub-rule (4) rule 25 and cancellation, if considered necessary by the Government authority, if it is found at a subsequent stage that information furnished by me/us is false.

Dated............................ Signature of the Applicants.

Signed before me:

No. Shri. ..................... Shri. ..................... Signature of the Magistrate/Tahsildar.

The Collector, ............................District.

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