Know Your Customer (KYC) Form (Request

ID: 19006813)

1) Personal Details
Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*:
First Name*:
Middle Name:
Last Name*:
Gas Consumer Number:
Name of Distributorship:
Father's Name*:
Mother's Name:

MR.
SURESH
NAMDEV
GURAV
(Only for existing customers)
APEX GAS SERVICE ( 110851 )
NAMDEV
SUGANDA

Date Of Birth*:

18-06-1990

(DD-MM-YYYY)

Spouse Name : SANJIVANI

2) Address for LPG connection / Contact Information

POA Category:
House/Flat#, Name :

Proof Of Address (POA)

POA03 - Lease Agreement
GANESH CHA

Housing Complex/Building :

GOLIBAR

Street/Road Name :
City/Town/Village:
District :
Mobile No :
Email ID:

6TH ROAD
MUMBAI
MUMBAI SUBURBAN
9920995295
starcentre.inc@gmail.com

POA Detail: BGHPG8567L

Floor No : NIL
Land Mark : SANTACRUZ
EAST
PIN Code: 400052
State : Maharashtra
Landline :

3) Other Relevant Details

POI Category:
State Of Issue:

Proof Of Identity (POI)

POI03 - PAN CARD Number
Ration Card Details if Available
Maharashtra

Card Number: BGHPG8567L

Ration Card Number: 0000

4) Bank Details
BankName:

Dena Bank

Account Type:
Name As In Account:

Savings
SURESH

IFSC/MICR/INN:BKDN046010
8
Account No:010810029851

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, BPC will be within its right to discontinue supply of LPG cylinders to me, forfeit of security deposit and can
levy penal charges as per the policy and guidelines and may initiate legal action applicable under provisions.
I also confirm that I do not have any objection in receiving SMS from BPCL on the mobile number given in this
form.
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
APEX GAS SERVICE

Date:

-------------------------------------------------Tear Off---------------------------------------------I/We, hereby, confirm receipt of duly filled in KYC form along with relevant POI, POA documents form
Name MR. SURESH NAMDEV GURAV Consumer no (if applicable) on____________________ (date)
Signature and Seal of Distributor