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I hereby declare that—

1. ¹[State of Maharashtra]¹ I intend to reside in the State of Maharashtra for a temporary period only and that I am only a visitor to the ¹[State of Maharashtra]¹.
2. I am ordinarily using and consuming foreign liquor;
3. I do not hold any permit under section 40, 40-A, 41, 46, or 47 of the Act nor have I made any other application for a permit under any of these sections;
4. the particulars given above are correct.

I hereby undertake—

1. 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;
2. to furnish such information or proof in support of my declaration as may be required now or hereafter.

Date

Signature of the applicant.

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

The Prohibition and Excise/Police/Customs Officer.

(Not to be filled in by the applicant)

Date of application

Permit prepared by and issued on

Received the permit No. on

Signature of the applicant.

Signature of the officer issuing the permit.