Know Your Customer(Kyc) Form

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Form KYC Version 3 - 2014-BPC
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*
of Birth*
b) Gas Consumer Number*
c) Date
D D M M Y Y Y Y
Close Relative
d)
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. I also confirm that in the event of any information provided by me is found incorrect / is incomplete and also in the event
of any violation of Government Regulation related to the supply and distribution of LPG, IOC/BPC/HPC will be within its right to
discontinue supply of LPG cylinders to me, forfeit of security deposit and levy of penal charges as per the policy and guidelines
and may initiate legal action applicable under provisions.
Name & Signature of Applicant *
Date:-
_______________________________________________________________________________________________________
To be filled by Distributor
I confirm having verified the photocopies of documents above against their originals.
Consumer Number (If allotted):
Signature of Distributor
Date:
Name of Distributorship with SAP Code
-----------------------------------------------------------------------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

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