Form KYC Version 3 - 2014-IOC/BPC/HPC
Know Your Customer(KYC) Form
(To be filled in black ink with BLOCK LETTERS. Fields marked with * are mandatory)
( For Instructions to fill form please see Overleaf)
1) Personal Details Paste your photo
here
(Mr./Mrs /Ms) *
First Name*
Middle Name
Last name*
b) Gas Consumer Number* c) Date of Birth*
D D M M Y Y YY
d) Close Relative Father’s /Spouse Name*
Mother’s name*
2) Address for LPG connection / Contact Information
Proof of Address ( POA) category Code* P O A
House/ Flat #, Name* Floor No*
Housing Complex/Building Land Mark
Street/Road Name
City/Town/Village * Pin Code*
District * State*
Phone #* : Mobile No Landline #
Email id
3) Other Relevant Details
a) Proof of Identity (POI)
POI Category Code* P O I
Card Number*
b) Ration Card Details if Available
State Of Issue
Ration Card Number
Declaration: I hereby declare that the information provided by me above is true and correct to the best of my knowledge and
belief. In
I also
caseconfirm
any of the thatabove
in theinformation
event of anyis information
found to be provided by meor
false or untrue is misleading
found incorrect / is incomplete Iand
or misrepresenting, am also
awarein that
the Ievent
may
of
beany
be heldviolation
held liable forof
liablefor it.Government
it. IIhereby Regulation
herebydeclare
declare that related
thatIIam
am not to thethis
notmaking
making supply
this and distribution
application
application for
forthe of LPG, of
thepurpose
purpose IOC/BPC/HPC
ofcontravention
contravention will
ofbe
of any
anywithin
Act, its right
Act,Rules,
Rules, to
Regulations
or any statute
discontinue
Regulations orofany
supplylegislation
of
statute orlegislation
of any notifications/directions
LPG cylinders to me, forfeit
or any issued
of security by any
deposit
notifications/directions andgovernmental
levyby
issued of any orcharges
penal statutory
governmentalas authority
per from
the policy
or statutory time to time.
and guidelines
authority from
timemay
and to time.
initiate legal action applicable under provisions.
Name & Signature * Date:-
_______________________________________________________________________________________________________
To be filled by Dealer/Distributor
I confirm having verified the photocopies of documents above against their originals.
Consumer Number (If allotted):
Signature of Distributor Date:
-----------------------------------------------------------------------Tear Off -----------------------------------------------------------------------------
Acknowledgement
I/We, hereby, confirm receipt of duly filled in KYC form along with copy relevant POI, POA documents from
Name _______________________________Consumer no (if applicable)_________________ on______________
Signature and Seal of Distributor
Instructions for Filling KYC Form
Fields marked with * are mandatory and must be filled in by person submitting KYC
1 a) Name Name to be entered as given in Photo ID Proof
1 b) Gas Consumer Mandatory for consumers already using LPG from IOC/BPC/HPC
Number
1 d) Details of Close Father or Spouse name is mandatory. Please strike off whichever is not
Relative applicable.
2 Proof Of Address At least copy of one of the documents listed below should be attached and
( POA) category mentioned in the form. The Address to be entered against the
relevant fields exactly as it appears in the POA. Person submitting KYC is
required to produce the original of document for verification by the distributor.
List of documents Category Code
Aadhaar (UID) POA01
Driving License POA02
Lease agreement POA03
Voter ID POA04
Telephone/Electricity /Water bill POA05
Passport POA06
Self-declaration attested by a Gazetted officer. POA07
Ration Card POA08
Flat allotment/possession letter POA09
House registration document POA10
LIC Policy POA11
Bank/Credit Card Statement POA12
3 a) Proof of Identity At least copy of one of the documents listed below should be attached and
(POI) category mentioned in the form. Consumer is required to produce the original
of the document for verification by the distributor.
List of documents Category Code
Aadhaar Number (UID/EID) POI01
Passport Number POI02
PAN Card Number POI03
Voter ID Card POI04
ID card Issued By Central/State POI05
Driving License POI06
