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Application No.: 002469

Maharashtra Natural Gas Ltd. Print Form

(A joint venture of GAIL (India) Ltd., & Bharat Petroleum Corporation Ltd.
Plot No. 27,Narveer Tanajiwadi,PMPML Bus-Depot Commercial building,Shivajinagar,Pune-411005.
Tel: 020-25611000, Fax: 020-25511522, Website: www.mngl.in
APPLICATION FORM CUM RECEIPT FOR REGISTRATION & SUPPLY OF DOMESTIC PIPED NATURAL GAS CONNECTION
I wish to register for Domestic Piped Natural Gas connection in the applied premises. My personal particulars and address are given hereunder.

PERSONAL DETAILS
Mr./Ms./Mrs. SURNAME FIRST NAME MIDDLE NAME
mr Agarwal Amit Kumar
DATE OF BIRTH Aadhar NO

10/11/1984 206717611266

INSTALLATION / CORRESPONDENCE ADDRESS

FLAT/ROOM NO FLOOR WING PLOT NO BUILDING NAME

18 5 H

SOCIETY NAME LANDMARK

RUNAL DEEPMALA CHS NEAR KOKANE CHOWK

AREA LOCATION CITY/DISTRICT

PUNE Pune
PIN E-MAIL ID MOBILE NO TELEPHONE (RES) TELEPHONE (OFF)

411027 [email protected] 9600137073

YOUR RESIDENCE IS [Y] OWNED [__] RENTED [__] LEASED [__] COMPANY PROVIDED
Which company's cylinder do you use? [__] IOCL (INDANE) [Y] HPCL (HP Gas) [__] BPCL (Bharat Gas)

DISTRIBUTOR NAME: BHAGWATI GAS SERVICE CONSUMER NO: 638886

FOR VERIFICATION
Proof of ownership attached: (Please tick) [__] Electricity Bill [__] Society Letter / receipt [__] Agreement [__] Index [Y] Property Tax Receipt

PAYMENT DETAILS (Please Do Not Pay by Cash)

PLEASE PAY BY CHEQUE / DD DULY CROSSED IN FAVOR OF "MAHARASHTRA NATURAL GAS LTD."
CHEQUE NO. BANK NAME

CHEQUE DATE BRANCH NAME

/
/
AMOUNT PAID : (Please tick whichever is applicable)
[__] Rs.500/- Application Fee (Non Refundable) [__] Rs.2500/- Registration Security Depotsit (Refundable)
[__] Rs.2500/- Registration & Connection Security Deposit (Refundable) [__] Rs.500/- Security deposit towards gas consumption (Refundable)
[__] Rs. ___________ Other charges if applicable (Non Refundable)

DECLARATION BY APPLICANT
1. I/We solemnly declare that the particular furnished above are true and correct. 2. I/We confirm that I/We have read and understood the terms and conditions hosted on the website. 3. I/We
accept and agree to the said Terms and Conditions as prevailing from time to time. 4. I accept that Maharashtra Natural Gas Ltd. is entitled in its absolute discretion to accept or reject this
application for Registration, without assigning any reason whatsoever. 5. I authorize Maharashtra Natural Gas Ltd. to verify the information stated in this form whatsoever source. I agree to
surrender LPG connection within 60 days of activation of PNG connection.
Applicant Signature
Date : / / Date of Online Submission : 2019-05-26 10:21:13
Name : _______________________
Note: 1.Cheque subject to realization in Maharashtra Natural Gas Ltd a/c., Please note that in case of dishonour of a cheque, Rs.150.00 would be paid by the customer towards administrative charges. This is prejudice to all our rights.

FOR OFFICE USE

NO OBJECTION CERTIFICATE
(To be filled by the lawful Owner Applicable only if the premiere is rented)

This is to certify that I,Mr./Mrs./Ms._____________________________________________________________________ am the lawful owner of the above-mentioned property. I have no
objection, if the tenant of the property as mentioned above, avails Domestic PNG connection from "Maharashtra Natural Gas Ltd."

Name: Mr./Mrs./Ms. __________________________________________________________________________________________________________________

Father's / Husband's Name : . __________________________________________________________________________________________________________
Permanent Address of Owner: _________________________________________________________________________________________________________
Landline (Office) : ____________________________________________________(Residence) _____________________________________________________

Mobile No : ________________________________________________Email ____________________________________________________________________

Proof of Ownership (as enclosed) _____________________________________________________Signature________________________________________

(FOR OFFICE USE) MNGL/PNG/DOM/2/00

CRN Project Area Name / Code Loop No

Agent Name: _____________________________________ Name of Supervisor: _____________________________________ Sign: ______________________

Verified by Marketing Incharge: Name: __________________________________________ Date: ___________________ Sign: ______________________

PAID

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Receipt for Application submitted

Received your application through our website Submitted on Please pay the Sum of Rs. 6550 /.

Application fees within 10 working days to enable us to process your application.

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