[OFFICIAL FORM G.] PERMIT-HOLDER'S BI-MONTHLY STATEMENT TO COUNTY AUDITOR, OF PURCHASES, SALES AND USE OF INTOXICA Gals. Qts. Pts. Gals. Qts. Pts. Gals. Qts. Pts. Gals. Qis. Pts. Gals. Qts. Pts. Gals. Qts. Pts. being duly sworn, on oath depose and say that the above and foregiong statement of purchases, aggregate sales and uses of intoxicating liquors, under my permit for the months of 189.., is a true and correct statement as I very believe. and Subscribed in my presence and sworn to before me by. day of A. D., 180.. on this County Auditor or Notary Public. I, .... Reg. Phar. No.... [OFFICIAL FORM H.] PERMIT-HOLDERS BI-MONTHLY REPORT OF REQUETS AND ...... .........., Reg. Phar. No........., being duly sworn on oath state that the requests for liquors herewith returned are all that were received and filled at my pharmacy (or place of business) under my permit during the months of .... and...... 189.., that I have carefully preserved the same and that they were filled up, signed and attested at the date shown thereon as provided by law, that said requests were filled by delivering the quantity and kind of liquors required, and that no liquors have been sold or dispensed under color of my permit during said months except as shown by the requests herewith returned, and that I have faithfully observed and complied with the conditions of my bond and oath taken by me thereon endorsed, and with all the laws relating to my duties in the premises. STATE OF IOWA, COUNTY.} SS Reg. Phar. No... first being duly sworn, depose and that no liquors have and say that I am clerk for been sold, dispensed or disposed of by me, in any manner, during the months of......... and...... except as shown by the requests at tested by me, filed herewith and included in the report of the said. and say that I am clerk for...... first being duly sworn, depose and that no liquors have been sold, dispensed or disposed of by me, in any manner, during the months of .....and....... ......... except as shown by the requests attested by me, filed herewith and included in the report of said........ The foregoing statement (was or were) subscribed to in my presence, as indicated therein, and sworn to before me by the said. said.. ..day of.. ....and ...and said..... on this A. D., 189.. County Auditor or Notary Public. [OFFICIAL FORM I.] RECORD OF PURCHASES AND USE OF INTOXICATING LIQUORS OF REGISTERED PHARMACISTS NOT HOLDING PERMITS. Gals. Qts. Pts. KIND. .189.... AMT. ON HAND AT COMMENCEMENT TOTAL ON HAND AMOUNT USED. AMT. ON HAND AT THE END OF THE Gal. Qis. Pts. Gals. Qts. Pts. Gals. Qts. Pts. Gals. Qts. Pts. [OFFICIAL FORM J.] BI-MONTHLY STATEMENT TO COUNTY AUDITOR OF PURCHASES AND USE OF INTOXICATING LIQUORS OF REGIS TERED PHARMACISTS NOT HOLDING PERMITS. For the months of. ..and.. .189.. I,.. ..county, Iowa, on oath depose and say that the above ..Reg. Phar. No of.. statement of intoxicating liquors purchased by me, and used at my pharmacy (or place of business) during the months of. ....and is true and correct in every particular, that the uses were only for compounding medicines and manufacturing phar189. maceutical preparations that could not be used as a beverage, and that I did not sell or use intoxicating liquors for any other purpose whatever. ... .... Subscribed in my presence and sworn to before me by .on this CERTIFICATE. OFFICE OF THE COMMISSIONERS OF PHARMACY, I, C. A. Weaver, Secretary of the Commission of Pharmacy for the State of Iowa, having custody of the register and records of the Commission, hereby certify that the regulations, opinions, forms and notices herein contained are true and correct copies of the original official regulations, forms, notices and opinions on file in this office. In testimony whereof I have hereunto set my hand and affixed the seal of the Commission. Done at Des Moines this [SEAL.] 31st day of Decemper, A. D. 1891. C. A. WEAVER, 3 |