(No. 3.)

Form of Notice of Application for a General Night License.

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

I, (slate the name) being the holder of a General License for the house and premises known as the "________________ Hotel," situate in the (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 Night License," under the "Licensing Ordinance 1865," in respect of the said hotel and premises.

Signed this day of one thousand eight hundred and________________

Signature of Applicant.