FORM "CERTIFICATE"

Certified that ME/Mrs./Miss/Messers of who has/have been granted an export pass No dated by has/have delivered the Indian-made foreign liquor as shown below on to of...................................... in the district of in the State of

and that the seals of the packages and receptacles containing the above foreign liquor were intact at the time of delivery of the consignment at its destination.

¹[Y*2. The importer has paid all duties and fees leviable under the Bombay Prohibition Act, 1949 on the quantity of Indian-made foreign liquor mentioned in the export pass, according to the rates prevailing in this State.]¹

Signature and designation of the Excise Officer at the importing place.

* Strike off if not applicable.