Schedule S.

Form of Application for Mem oval of License.

To the Worshipful the Justices of the Peace acting in and for the Licensing District of in the Province of Otago.

I, A. B. (here state place of residence, the house licensed the sign if any) being the holder of a (here state nature of license) license under the "Licensing Ordinance 1865," in respect of the said house and premises, do hereby apply for permission to remove my business from the said house to (here state the house to which license is to be removed, describing its situation, sign or any other particulars)

Given under my hand____________at____________this____________day of____________

A. B.