FORM EL./A-7

FORM EL./A-7

(See rule 71)

Application No.

1. Title शीर्षक

1. Name, designation and address of the applicant in full. (Surname first in BLOCK letters.).
2. Name and address of the institution*
   No. of the ambulance and the name and address of the institution to which it belongs name and address of the 'first-aid station**
   Name or No. of the Air-craft*..
3. Age.
4. Occupation.
5. Quantity of brandy and rum required during a month.

I hereby declare that the particulars given above are correct.

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

Date:

Signature of the applicant.

The Collector of

Strike out where not applicable.