Schedule "M" (Form R-17) - Alcoholic Beverage Transportation Page 2

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R-17

(9-97, Rev. 2)

Page 2

SCHEDULE “M”

Picked up at: Name & Address of

No. & Kind of

No. & Size of

Transferred for Delivery

Date of

Date of Pick-up and

Licensed Premises, Warehouse,

Name & Address of Consignor

Name & Address of Actual Consignee

* Kind of

Pkgs., such

Containers,

to Other Transporter

Delivery

Pro No.

Railroad, Forwarding Company,

(Actual Shipper, Not a Pier,

(Not of Another Transporter,

Beverage

as Bbl.,

12/Qts., 24/Pts.,

Name and Address of Transporter

Etc.

Ship or Pier

Warehouse, or Transporter)

Pier or Warehouse)

Case, etc.

* IN COLUMN HEADED “KIND OF BEVERAGE”, CLASSIFY AS EITHER BEER, LIQUOR, ALCOHOL, STILL WINES, VERMOUTH, SPARKLING WINES (including apple cider with more than 7% alcohol) or APPLE CIDER (3.2% to 7% alcohol).