KYC Format HPGAS V3 1

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)

Paste your photo here 1) Personal Details
(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
POI Category Code*

a) Proof of Identity (POI)
P O I

Card Number*
State Of Issue

b) Ration Card Details if Available

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 *
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