ose APPLICATION FOR DEPOSIT FREE CONNECTION 1. To not bave any LPG connection and 1am desirous of obtaining a Single Gplinder / DBC connection. I may be ised necessary Authority Leiter to enable me to obtain without deposit HP Gas /Indane / Bharat Gas Single Cylinder DBC connection oR 1am holding a single cylinder of HP Gas Indane/ Bharat Gas connection and Tam desirous of availing second eylinder without security deposit. may be issued necessary Authority Leter to enable me to obtain Second Cylinder ‘without deposit and also refind ofthe security deposit already paid for Single Cylinder. oR am holding « Single Cylinder of HP Gas /Indane / Bharat Gas connection without security deposit Iam desirous of availing Second Cylinder without Security deposit. I may, therefore be issued necesary Authority Letter to ‘enable me to avail of he facility of Second Cylinder without deposit. oR 1 am holding a HP Gas / Indane / Bharat Gas Single Cylinder ! DBC connection and I have paid security deposit for Single Cylinder / DBC connection. I may be issued necesary Authority eter to met cbtain send ‘of sccutity deposit paid by me for Single Cylinder / DBC connection, 2. Incase application is for secking [New Connection, sate whether Single Cylinder / DBC is required DRL. 3. Incase application is for socking Additonal Cylinder (DBC), give the following details (@) Consumer Number (@)No. & Date of SV 4. In case the application is for seeking refund of security deposit give the following details (@) Consumer Number ()No. & Dateof SV (©) Equipments (@) Amount of deposit tobe refunded RS.5. (a)Name, EmployeeNo. & Address ofthe -Aetélnd fumad Mecea employee seeking refund |New connection Est Page 2 BLISESE « Abbe ss! M20.) LENETESH APART MENTS , ANGOLA eon, jiasimas:TEE, PAL.AN eve VN & Ado he Discouer SATYM A GGLN- Han dpi ft 7 PLEX addtec, 0 Ploeg, Su Kiasinsal, ALG EO, GANASEAN! Ah. 28510 6. Undertaking tobe given in ate Subscription Vouchers lostmisplaced “Since # Subscription Voucher isued in my favour by the aforesaid Aistibutor recording therein the details of equipments loened to me and the acknowledgement of the amount having been received by the said sistibutor has been misplaced/ost and the same is nt traceable in spite of ‘ue and diligent serch made by me, I the undersigned hereby undertake to fully and effectually indemnity and keep indemnified the Corporation ‘gains all claims, actual demands, losses, damages costs, charges and any ‘other expenses that the Corporation might sulfer and be put o by eason of refunding the sum covered by the said SV. and I will undertake to retum tthe Corporation the sid 8,V. if found hereafer2” 7. tis further agred and understood by me that if ease tobe employee ofthe Corporation for any reason whatsoever except by way of Superannuation ‘Pesmanent disablement, I wll not be entitled forthe benelt under the ebove scheme and I undeake 10 pay immediately the security deposit for the ‘equipments losned to me. Incase I commit a breach of agreement mentioned in para 6 the Corporation slall be ented to recover the deposit, the amount that may be found duc and payable by the Corporation tome of recover the equipments loaned to me purely at my risk andthe cost and consequence thereo, ee Signature aoe Name; ARS ABE MECN EnployeoNo,-p-BI4ERCAQ, Denipaton Signature of Department Head (Rubber Stamp) Mivtete teaent * sire out whichever ino applisable. Pevnaga —Prayeahe one aa REO CATT ADE, “tensa wy eke” REE ARSE lapPhe a APPLICATION FOR DEPOSIT FREE CONNECTION, 1. Io not have any LPG connection and I am desirous of obtaining @ Single Cinder / DBC connection. I may be issued necessary Authority Leter to enable me to obiain without deposit HP Gas /Indane / Bharat Gas Single Onder DBC conection oR | am holding a single cylinder of HP Gas Tndane / Bharat Gas connection and 1am desirous of availing second eylinder without secutty deposit T may be issued necessary Authority Leter to enable me to obtain Second Cylinder ‘without deposit and als refund ofthe security deposit slready paid for Single Cinder oR 1am holding a Single Cylinder of HP Gas /Indane / Bharat Gas connection without security deposit. Iam desirous of avaling Second Cylinder without seouity deposit. I may, therefore be iswued necesaty Authority Letter t0 cable me io avail of the facility of Sacond Cylinder without depost. oR | am holding a HP Gas / Indane / Bharat Gas Single Cylinder / DBC sonneetion and I have paid security deposit for Single Cylinder / DBC connection. I may be issued necessary Authority Letter to me to obtain refund of security deposit pad by me fr Single Cylinder / DBC connection. 2. In case application is for secking [New Connection, state whether ~ Single Cylinder / DBC is required Ds 3. Incase application is for seeking Additions Cylinder (DBC), give the following details (@) Consumer Number No. & Dateof SV 4 In case the application is for seeking refund of security deposit give the following details: (@) Consumer Namber ()No. & Date of SV (©) Eauipments (@) Amount of deposit to be refunded RS. ~ =Page 2 5. (@) Name, EmployeeNo. & Address ofthe ‘employee Seeking refund /New conection ~ (Name & Address ofthe Distributor saver Sanjay Kuma. Meena, EmbSio. 1564 ey ele. Si sesh Whe “EHR Foy nparcen ayer we Zana Bie thechendior, “ular Dig Boggatertn 4) 6. Undertaking wo be given in case Subscription Vouchers lostnisplaved “Since » Subscription Voucher issu in my favour by the aforesaid Aistibutor roording therein the details of equipments loaned to me and the acknowledgement ofthe amount having been received by the said distributor has beea msplacedlos and the same isnot traceable inspite of due and diligent search made by mo, I the undersigned hereby undertake ‘to fully and effectually indemnity and keep indemnified the Conporstion sgainst all claims, sctsl demands, losses, damages costs, charges and any ‘other expenses tht the Corporation might suffer and be 10 by reason ‘of refunding the sum covered by the said S.V. and I will undertake to return to the Corporation th sid 8,V. i found hereafter.” 17. tie further agreed snd understood by me that if cease tobe employee of the Corporation for any reason whatsoever except by way of Superannuation ‘Permanent disablement, wil not be ented forthe benefit under the above scheme and T undertake to pay immodistely the security deposit for the equipments loaned tome. 8. Incase I commit a breach of agreement mentioned in pare 6 the Corporation shall be entitled to recover the dopo, the amount that may be found du and peyable by the Corporation to me of recover the equipments loaned to me purely at my risk and the cost and consequence thereof Designation (@ubber Stamp) * Strike out whichever is not appicabie) ~—* Employee No, are Sort ele Senay Sarah “hui peat Paisnur.