“I hereby state that my name is ____; that my postoffice address is ____ Mississippi; that I am more than twenty-one years of age; that I am the consignee to whom the package containing ____ of alcohol or wine (as it may be) was consigned at ____ on the ____ day of ____ 2____ to be used for (set out the use for which they are to be used). I will not use this liquor in violation of any law of this state.
Signed and dated at ____, Miss., this ____ day of ____ 2____.
____ Consignee.
By ____, Agent of the consignee.”
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