Hpgas Distributor Know Your Customer (Kyc) Form

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KYC:HPCL-II-071212
HPGAS Distributor name:
_
Know Your Customer (KYC) Form
(To be filled in black ink with BLOCK LETTERS by consumer while registering for LPG Gas connection
* are mandatory)
Paste your photo
1.
Customer Details *
here
a.
Name shall be entered as per Photo ID Proof)
(Mr./Ms./Mrs/Miss/Dr) *
First Name*
Middle Name
Last name*
b. Gas Consumer Number
(Mandatory for existing customers)
Date of Birth*
c.
2. Details of Close Relatives
D
D
M
M
Y
Y
a. Father’s Name*
b. Mother’s Name
c. Name of Spouse
Proof of address (POA)
one
3.
(At least copy of
of the following documents listed below is to be attached/scanned with
this form. Consumer is required to produce the original of document for verification by the distributor, when sought for. Kindly
tick the POA provided by you below and fill up address details in S.No. 4 below accordingly)
Aadhaar (UID)
Driving License
Lease agreement
Voter ID
Telephone/Electricity /Water bill
Passport
Self-declaration attested by a Gazetted officer.
Ration Card
Flat allotment/possession letter
House registration document
LIC Policy
Bank/Credit Card Statement
Connection Address/Contact Information
4.
* (Address should be written as per Proof of Address)
House # *
House Name/Flat Floor #
Housing Complex/Building #
Street/Road Name
City/Town/Village *
District *
State *
PIN Code *
Furnish here any other address related Information which is not in the Proof of Address, but will help locate the house (Floor, landmark etc)

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