Hpgas Distributor Know Your Customer (Kyc) Form Page 2
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2KYC:HPCL-II-071212
Contact Number (landline)
Mobile Number
@
Email
Proof of Identity (POI)
5.
one
( Serial numbers of all POIs you hold should be provided. At least copy of
of the following
PHOTO ID document MUST be attached /scanned with this KYC, which should be VALID and should be ticked in last column. This
POI in original is required to be produced for verification by the distributor when sought for.)
Issuing
Tick if
POI Type
Authority
ID Card Number
attached
(Mention)
Aadhaar Number (UID/EID)
UIDAI
Passport Number
RPO
PAN Card Number
GOI
Voter ID Card
ID card Issued By
Central/State
Driving License
Ration Card
6.
: ( In case your name is appearing in any ration card issued by the State Government please provide
the card number
State of Issue
and the Name of
Card Number
the State
Government )
Optional Bank Account details
7.
( Fill if you desire the notified subsidy to be transferred to your bank
account as and when conditional direct transfer of subsidy commences – in that case please give a copy of
cancelled cheque also)
a.
Bank Name
b. Branch & Address
c.
IFSC Code
d. Bank Account Number
Declaration: I hereby 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/ is incomplete and also in the
event of any violation of Government Regulation related to the supply and distribution of LPG, the OMC will be well within its right
to take necessary legal action including discontinuation of supply of LPG cylinders to me, forfeiture of my security deposit, and levy
of penal charges as per the policy and guidelines.
I am willing/not willing to avail the Subsidy on LPG cylinders, in event of direct conditional transfer of cash subsidy, and therefore
have provided/not provided my Bank account details above (strike off not applicable)
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 copy relevant documents of Proof of Identity and Proof of
Address from (consumer#) ----------------------------------------- on dated---------------- Signature and Seal of Distributor
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Parent category: Business