1[FORM E.L.M.C.-2]

Full address of the applicant:

Station Signature of the Registered Medical Practitioner and his name and Registration No.

Date:

[FORM E.L.X-C

(See rule 70-D)

Shri/Smt./Kum age residing at is hereby permitted to purchase, possess, transport, use and consume foreign liquor and country liquor within the State of Maharashtra, subject to the provisions of the Bombay Prohibition Act, 1949, and the rules, regulations and orders made there under, during the period commencing on the date on which this permit is granted and ending on

Place:

Date:

Seal of the Office Signature of Officer.

Specimen Signature or thumb impression of the permit-holder.

(To be filled in and handed over to the Officer issuing permit for grant of permit for subsequent period).

I declare that, I continue to require foreign liquor and country liquor for preservation and maintenance of my health.

Place:

Date:

Signature or thumb impression of permit-holder.]

Ins. by G. N. of 8-8-1979.