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    Indane Gas New Connection Application Form PDF

    Uploaded by

    Евгений Булгаков
    This document is a consumer information sheet for registering for an LPG gas connection. It requests personal details such as name, date of birth, address, ID numbers, and contact information. It also asks for documentation to verify identity and address. The applicant must declare that the information provided is true and complete, and agrees to terms of use. The distributor section is for recording the consumer number, signature, and receipt of the KYC form and documents.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Indane Gas New Connection Application Form PDF

    Uploaded by

    Евгений Булгаков
    6K views2 pages
    This document is a consumer information sheet for registering for an LPG gas connection. It requests personal details such as name, date of birth, address, ID numbers, and contact information. It also asks for documentation to verify identity and address. The applicant must declare that the information provided is true and complete, and agrees to terms of use. The distributor section is for recording the consumer number, signature, and receipt of the KYC form and documents.

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    indane gas new connection application form pdf

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    This document is a consumer information sheet for registering for an LPG gas connection. It requests personal details such as name, date of birth, address, ID numbers, and contact information. It also asks for documentation to verify identity and address. The applicant must declare that the information provided is true and complete, and agrees to terms of use. The distributor section is for recording the consumer number, signature, and receipt of the KYC form and documents.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    6K views2 pages

    Indane Gas New Connection Application Form PDF

    Uploaded by

    Евгений Булгаков
    This document is a consumer information sheet for registering for an LPG gas connection. It requests personal details such as name, date of birth, address, ID numbers, and contact information. It also asks for documentation to verify identity and address. The applicant must declare that the information provided is true and complete, and agrees to terms of use. The distributor section is for recording the consumer number, signature, and receipt of the KYC form and documents.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 2

    Distributor Name:

    (To be filled by consumer while registering for LPG Gas connection)

    Particulars
    Please write correct details as given in documents
    Paste your photo
    Name of Consumer* here

    Salutation (Mr./Ms./Mrs/Miss) *

    First Name*

    Middle Name

    Last Name*
    (Name shall be entered as per Photo ID Proof)

    Consumer Number
    (only for existing customers)
    Date of Birth*

    D D M M Y Y
    Father’s Name*

    Mother’s Name

    Name of Spouse

    Address* Address shall be written as per Proof of Address

    House No *

    House Name/Flat Floor No *


    Housing Complex/Building
    No. *

    Street/Road Name *

    Area/Land Mark

    City/Town/Village *

    District *

    State *

    PIN Code *

    Telephone Number

    Mobile Number

    Email ID @
    * Mandatory Fields
    CONSUMER INFORMATION SHEET (Page 2)
    At Least one of the following documents of Proof of Address is Mandatory. Kindly tick the document provided for Proof of Address

    Aadhaar (UID) Driving License No


    Lease agreement / rent receipt Voter ID No
    Telephone/Electricity or any other utility bill Passport
    Self-declaration attested by Gazetted officer. Ration Card
    Flat allotment/possession letter House registration document
    LIC Policy

    Physically
    Do you have Pan Number: Yes/No Verified by Distributor?

    If Yes, Please enter PAN Number Yes No

    Do you have a Passport: Yes/No


    If Yes, Please enter Passport Number Yes No

    Do you have a Driving License: Yes/No


    If Yes, Please enter Driving License No Yes No

    Do you have a Ration Card : Yes/No


    If Yes, Please enter Ration Card No Yes No

    Do you have UIDAI Adhaar No: Yes/No


    If Yes, Please enter your Adhaar No Yes No

    Do you have Voter ID (EPIC-Election Photo ID Card): Yes/No


    If Yes, Please enter your Voter ID No Yes No

    Do you have Id Issued By Central State Government): Yes/No


    If Yes, Please enter your ID No Yes No

    Optional Details

    Bank Name

    Branch & Address

    IFSC Code

    Account Number

    Declaration: I declare that the information provided by me on the above form is true and correct to the best of my knowledge and
    belief. I also confirm that in the event of any information provided by me is not true and incomplete and also in the event of any
    violation of Government Regulation related to the supply and distribution of LPG, IOCL will be well within its right to take necessary
    action including discontinuation of supply of LPG cylinders, can forfeit the security deposit and can levy panel charges as per the
    policy and guidelines. I am willing/not willing to avail the Subsidy on LPG cylinders therefore I have provided/not provided my Bank
    account details on the above request form

    Name & Signature of Customer * Date:

    To be filled by Dealer/Distributor
    Consumer Number (If allotted): Date:

    Signature of Distributor

    ------------------------------------------------------------------Tear Off----------------------------------------------------------------------
    I/We, hereby, confirm receipt of duly filled in KYC form along with relevant documents of Proof of Identity and Proof of Address has
    been received from ----------------------------------------- on---------------- (date)

    Signature and Seal of Distributors

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