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788 Bombay Prohibition Act, 1949 [1949 : Bom. XXV (3)Age and date of birth. ................................................................................. (4)Particulars of proof of age. ................................................................................. produced with the application (5)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 Dr. ................... ...................Registered Medical Practitioner, in support of my 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 thereunder. Place : Date : Signature or thumb impression of the applicant. To, The Collector of ................................ (or authorised Officer). *[for applicants in Wardha District only].

[(See rule 70-D)] Application Form F. L./A-6D No. ............................................................................................... Certificate of a Registered Medical Practitioner/Government Medical Officer recommending the grant of permit to possess and use foreign liquor and country liquor for personal consumption. This is to certify that Shri/Smt./Kum. ................................................................................ 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 for 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 Govern- ment Medical Officer and his name.] 1.Ins. by G. N. of 8-8-1979. 2.Subs. by G. N. of 4-5-1982.