Maharashtra Excise Manual
Page 784 of 1109

FORM EL./A-3

FORM EL./A-3

[See rule 67(1)]

Application No.

Application for a permit to possess foreign Liquor for medicinal use on emergent occasions

  1. Name in full Shri/Smty Kumari .. (Surname first in BLOCK letters)
  2. Residential address in full ..
  3. Nationality ..
  4. Religion ..
  5. Age ..
  6. Occupation ..
  7. Monthly Income ..
  8. Kind of liquor required ..
  9. Whether the applicant is head of household I declare that —
    1. I usually keep * for medicinal use.
    2. I have at present got stock of * as under: (Here state the stock)
    3. Neither I nor member of my house hold holds any Emergency Permit nor have I or any member of my household has applied for any such permit.
    4. 1(cc) I have +/have not been convicted on (date) +/ at any time of an +/any offence punishable under sections +/any provisions of the Bombay Prohibition Act, 1949. There is a +/is no prosecution under sections +/any provisions of the said Act pending against me in the +/any Court in Maharashtra State.1
    5. The particulars given above are correct.

I, hereby undertake to abide by the conditions of the permit and the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under.

Signature of the Applicant.

Dated:

The Collector of ........... ............ ............ ............ District