Form KYC Version - II - 071212

____________________________ Know Your Customer(KYC) Form

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(To be filled in black ink with BLOCK LETTE ! b" consumer while re#isterin# for L$% %as connection * are mandatory)

1.

Customer Details * a. &ame shall be entered as 'er $hoto () $roof)

(Mr./Ms./Mrs/Miss/Dr) *

&irst #ame' (iddle #ame )ast name' b. Gas Consumer Number

(*andator" for e+istin# customers)

c. Date of Birth*
) ) * * Y Y

2. Details of Close Relatives

a.

Father s Name*

b.

Mother s Name

c.

Name of !"ouse

3. #roof of address (#$%) (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 !A provided by you below and fill up address details in ".#o. $ below accordingly% %adhaar (&'D) )ease a(reement ,ele"hone/-le*tri*ity /.ater bill !elf/de*laration attested by a Ga0etted offi*er. Flat allotment/"ossession letter )'C #oli*y Drivin( )i*ense +oter 'D #ass"ort Ration Card 1ouse re(istration do*ument Ban2/Credit Card !tatement

4. Conne*tion %ddress/Conta*t 'nformation* (,ddress should be written as 'er $roof of ,ddress) *ouse + ' *ouse #ame/&lat &loor + *ousing Comple,/-uilding + "treet/.oad #ame City//own/0illage ' 1istrict ' "tate ' 2# Code '
&urnish here any other address related 2nformation which is not in the roof of Address, but will help locate the house (&loor, landmark etc%

Conta*t Number (landline) Mobile Number

-mail

. #roof of 'dentity (#$') ( "erial numbers of all !2s you hold should be provided. At least copy of one of the following *!/! 21 document (3"/ be attached /scanned with this K4C, which should be 0A)21 and should be ticked in last column. /his !2 in original is required to be produced for verification by the distributor when sought for.%
'ssuin( %uthority (Mention)
&'D%' R#$ G$' ,i*2 if atta*hed

#$' ,y"e

'D Card Number

%adhaar Number (&'D/-'D) #ass"ort Number #%N Card Number +oter 'D Card 'D *ard 'ssued By Central/!tate Drivin( )i*ense

!. Ration Card : ( In case your name is appearing in any ration card issued by the State Government please provide
the card number and the Name of the State Government ) !tate of 'ssue Card Number

7. $"tional Ban2 %**ount details ( Fill if you desire the notified subsidy to be transferred to your ban2
a**ount as and 3hen *onditional dire*t transfer of subsidy *ommen*es 4 in that *ase "lease (ive a *o"y of *an*elled *he5ue also) a. b. Ban2 Name Bran*h 6 %ddress

*.

'F!C Code

". Ban2 %**ount Number

De*laration- ( hereb" declare that the information 'ro.ided b" me on the abo.e form is true and correct to the best of m" knowled#e and belief/ ( also confirm that in the e.ent of an" information 'ro.ided b" me is not true0 is incom'lete and also in the e.ent of an" .iolation of %o.ernment e#ulation related to the su''l" and distribution of L$%1 the O*C will be well within its ri#ht to take necessar" le#al action includin# discontinuation of su''l" of L$% c"linders to me1 forfeiture of m" securit" de'osit1 and le." of 'enal char#es as 'er the 'olic" and #uidelines/ ( am willin#0not willin# to a.ail the !ubsid" on L$% c"linders1 in e.ent of direct conditional transfer of cash subsid"1 and therefore ha.e 'ro.ided0not 'ro.ided m" Bank account details abo.e (strike off not a''licable) Name 6 !i(nature of Customer * Date7 ,o be filled by Dealer/Distributor Consumer Number ('f allotted)7 Date7 !i(nature of Distributor //////////////////////////////////////////////////////////////////,ear $ff////////////////////////////////////////////////////////////////////////////////////// '/.e8 hereby8 *onfirm re*ei"t of duly filled in 9:C form alon( 3ith *o"y relevant do*uments of #roof of 'dentity and #roof of %ddress from (*onsumer;) ///////////////////////////////////////// on dated//////////////// !i(nature and !eal of Distributor