Form E L. R. 10
[See rule 16(4)]
Register showing full names and addresses of registered medical practitioners on whose prescription champagne. Port-type Wine, Port- Wine, Wincarnis, Vibonas, Manola and Bukfast Tonic Wine, were sold by the licensee and of the persons to whom they were sold
| Licence No Name of the licensee | |||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Name of registered medical practitioners on whose prescriptions Champagne, etc. is sold by licensee | Name of persons to whom Champagne or Port-wine is sold on prescription | Name and quantity of wine prescribed and sold | |||||||||||
| (1) Date | (2) No. | (3) Date | (4) Full Name | (5) Address | Registration No. | Full Address | Name | Quantity of wine sold ml. | |||||
| Name and total quantity of wine sold on prescriptions during the day | Whether the total quantity has been entered in the stock register of the licensee and if so, at what page | Signature of the licensee or his authorised servant | Remarks | ||||||||||
| (6) Cash memo No. | Name of wine | (7) Quantity ml. | (8) | (9) | (10) | ||||||||
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