Behanchod
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)
1. Customer Details *
a. Name shall be entered as per Photo ID Proof)
(Mr./Ms./Mrs/Miss/Dr) *
b. Gas Consumer Number
(Mandatory for existing customers)
c. Date of Birth*
2. Details of Close Relatives
a. Father’s Name*
b. Mother’s Name
c. Name of Spouse
3. Proof of address (POA) (At least copy of one 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
4. Connection Address/Contact Information* (Address should be written as per Proof of Address)
First Name*
Middle Name
Last name*
D
D
M
M
Y
Y
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)
Paste your photo here
KYC:HPCL-II-071212
Email
5. Proof of Identity (POI) ( Serial numbers of all POIs you hold should be provided. At least copy of one 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.)
6. Ration Card : ( In case your name is appearing in any ration card issued by the State Government please
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)
1. Customer Details *
a. Name shall be entered as per Photo ID Proof)
(Mr./Ms./Mrs/Miss/Dr) *
b. Gas Consumer Number
(Mandatory for existing customers)
c. Date of Birth*
2. Details of Close Relatives
a. Father’s Name*
b. Mother’s Name
c. Name of Spouse
3. Proof of address (POA) (At least copy of one 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
4. Connection Address/Contact Information* (Address should be written as per Proof of Address)
First Name*
Middle Name
Last name*
D
D
M
M
Y
Y
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)
Paste your photo here
KYC:HPCL-II-071212
5. Proof of Identity (POI) ( Serial numbers of all POIs you hold should be provided. At least copy of one 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.)
6. Ration Card : ( In case your name is appearing in any ration card issued by the State Government please