CONSUMER INFORMATION SHEET
KABANI HP GAS AGENCY
KABANI
KABANI
ELAMPILLAI
Name of the Distributorship : gth HP
ghuHP GAS
GAS
nf AGENCY
AGENCY
gh, U
ELAMPILLAI
ELAMPILLAI Paste your Phote here
Name of Consumer* / thoifahs bga : nghnlh
Salutation (Mr./Ms./Mrs/Miss) / :
First Name* / Kj bga :
Middle Name* / il bga :
Last Name* / fil bga :
(Name to be entered as per Photo ID Proof)
Consumer Number / thoifahs nf v :
(Only for existing Customer)
Date of Birth / wj nj :
D D M M Y Y Y Y
Fathers Name* / jij bga :
Mothers Name* / jh bga :
Name of Spouse* / th bga :
Address* / Kft (Address to be written as given in Proof of Address)/Kft mjhl Kft FLf :
House No* / L v :
House Name/Flat Floor No* / L / sh v :
Housing Complex / Building No. :
Street / Road Name* / / bjU bga :
Area / Landmark* / Vah / nykh :
City / Town / Village* / efu / l / uhk :
District* / khtl :
State* / khy :
Pincode* / nfhL :
Telephone Number* / bjhiyng v :
Mobile Number* / bkhig v :
E-mail ID / bk : @
* Mandatory Fields
CONSUMER INFORMATION SHEET (Page 1)
Atleast one of the following documents of Proof of identity is Mandatory. Kindly tick the Atleast one of the following documents of Proof of identity is Mandatory. Kindly tick the
document provided for Proof of Address / document provided for Proof of identity /
Kft mjhF Ta vitnaD xU b#uh ntL. bga mjhF Ta vitnaD xU b#uh ntL.
Aadhaar (UID) Letter / Mj byl Pan card / ng fhL
Lease agreement / rent receipt / / thlif xgj Passport / ghngh
Telephone / Electricity or any other utility bill / bjhiyng/flz/ju Voter ID / thfhs milahs mil
Self declaration attested by Gazetted officer Aadhaar (UID) Letter / Mj byl
Flat allotment / possession letter / sh myhbk / nghr byl Driving License / oiu iybr
LIC policy / v.I. gh Voter ID / thfhs milahs mil
Driving License / oiu iybr Central / State Government Issued ID Card / ka / khy mu milahs mil
Voter ID / thfhs milahs mil
Passport / ghngh
Ration Card / nur fhL
House registration document / L gu
Do you have Pan Number : Yes / No ng fhL v M / iy Physically Verified by Distributor?
If Yes, Please enter PAN Number
Yes No
Do you have a Passport : Yes / No / ghnghL v M / iy
If Yes, Please enter Passport Number
Yes No
Do you have a Driving License : Yes / No / XLe ck v M / iy
If Yes, Please enter Driving License Number
Yes No
Do you have a Ration Card : Yes / No / nu fhL v M / iy
If Yes, Please enter Ration Card Number
Yes No
Do you have Adhaar No : Yes / No / Mj v M / iy
If Yes, Please enter Adhaar No
Yes No
Do you have Voter ID (EPIC-Election Photo ID Card) : Yes / No / thfhs mil v M / iy
If Yes, Please enter Voter ID Number
Yes No
Do you have id Issued By Central State Government) : Yes / No / ka/khy mu milahs mil v M / iy
If Yes, Please enter your ID Number
Yes No
Optional Details
Bank Name / t bga
Branch & Address / is / Kft
IFSC Code / t IFSC Code
Account Number / mf be.
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, H
BPCL 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.
thFW : eh nk Ta tuf midJ cik. vdJ nf izig bgWtjfhf eh jj tuf Vnj cik iy v
HP bgnuha fhnu blF cik UwJ. vdF L cgnahf
nf izig uJ bra kW ntW eltoif vLf ghu
nffhd kha ntL / ntlh. Mifah v t mf tufis j ghuJl jUnw / juiy.
Signature of Customer*/thoifahs ifbahg Date*/nj
Signature of Distributor*/nahfj ifbahg Date*/nj
------------------------------------------------------------------ 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)
............................................................................................ Tear off .........................................................................................
I/We, hereby, conform 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)
