(No.1.)

Form of Notice of Application for a General License.

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

I, (state the name and the trade or occupation) now residing at________________ (city, town or district of)________________ do hereby give notice that it is my intention to apply at the next Quarterly Licensing Meeting to be holden for this district, on the________________ day of________________ next ensuing, for a General License, under the "Licensing Ordinance 1865" for the sale of Fermented and Spirituous Liquors, in the house appurtenances thereunto belonging situate at (here describe the house proposed to be licensed, specifying the situation of it, the number of sitting-rooms and bed rooms contained in it, exclusive of those required for the family, the person from whom rented, the present occupier, whether now licensed, and if so, under whut sign) and which I intend to keep as an Hotel, Inn, or Public House.

Signed this day________________ day of________________ one thousand eight hundred and________________

Signature of Applicant.