Whether any Excise/Police/Municipal licence held by the applicant is or was cancelled at any time in the past, and if so, the reasons for such cancellation.
Whether the applicant is in excise arrears or in arrears of any other Government dues, such as sales tax, income tax, etc.
I hereby declare that the particulars given above are correct.
I hereby undertake to abide by the conditions of the licence and the provisions of the Bombay Prohibition Act, 1949 and the rules, regulations and orders made there under from time to time.
Signature of the Applicant.
Date:
The Collector of.....................................................................