Age and date of birth
Particulars of proof of age produced with the application
Occupation
♦[I hereby declare that I require mild liquor for the preservation and maintenance of my health.]♦
I sumbit herewith the medical certificate in Form F. L. M. C.-2 signed by Dn Registered Medical Practitioner, in support ofmy application.
I hereby undertake to abide by the conditions of the permit and the provisions of the Bombay Prohibition Act, 1949 and rules, regulations and orders made there under.
Place:
Date: Signature or thumb impression of the applicant.
The Collector of (or authorised Officer).
JFORME LJM.C-D1
2[See rule 70-D]2
Application Form E L./A-6D No. ..................----------- ..... .................
Certificate of a Registered Medical Practitioner/Government Medical Officer recommending the grant ofpermit to possess and useforeign liquor and country liquorfar personal consumption.
This is to certify that Shri/SmtJKum of by his/her statement aged years and is apparently about years of age and that he/she requires foreign liquor and/or country liquor fbr the preservation and maintenance of his/her health. The grant of the permit to him/her is recommended.
Signature or thumb impression of the applicant
Full address of the applicant:
Signature of the Registered Medical Practitioner and his name and Station registration number.
Date: Signature and Designation of a Government Medical Officer and his name.
- Ins. by G N. of 8-8-1979.
- Subs. by G N. of 4-5-1982.