R INFORMATION SHEET (Wait list ID: 7472843)

Name of Distributorship:

Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*: MR.
First Name*: BASUDEB
Middle Name: NONE
SHARMA
Last Name*: (Name to be entered as per Photo ID
Proof)
Consumer Number:
(Only for existing customers)
15-01-1976
Date Of Birth*:
DD-MM-YYYY
Father's Name*: KISHORI SHYAM
Mother's Name: KIRAN DEVI
Name Of Spouse: GOURI SHARMA

Address* (Address to be written as given in Proof of Address)

House No*: 67
House Name/Flat Floor No*: NONE
Housing Complex/Building No*: MCF
Street/Road Name*: 3A
Area/Land Mark: KHEDADEVAT MANDIR
City/Town/Village*: BALLABHAGARH
District*: FARIDABAD, HARYANA
State*: Haryana
PIN Code*: 121004
Telephone Number: 129428432
Mobile Number: 9711149256
Email ID: svasudev22@yahoo.com
* Mandatory Fields
At least one of the following documents of Proof of Address is At least one of the following documents of Proof of Identity is
mandatory. Kindly tick the document provided for Proof of mandatory. Kindly tick the document provided for Proof of
Address Identity
. Aadhaar (UID) letter . PAN Card
. Lease agreement / rent receipt . Passport
. Telephone/Electricity or any other utility bill . Voter ID
. Self-declaration attested by Gazetted officer . Aadhaar (UID) letter
. Flat allotment/possession letter . Driving License
. LIC Policy . Central/State Government Issued ID Cards
. Driving License . -
. Voter ID . -
. Passport . -
. Ration Card . -
. House registration document . -
CONSUMER INFORMATION SHEET (Page 2)
Physically
Do you have Pan Number: Yes Verified by Distributor?
If Yes, Please enter PAN Number: CARPS8691A Yes  No
Do you have a Passport: Yes
If Yes, Please enter Passport Yes  No
Number: L1834217
Do you have a Driving License: Yes
If Yes, Please enter Driving License Yes  No
No: 569-B-2000
Do you have a Ration Card : Yes
Yes  No
If Yes, Please enter Ration Card No: 4107453
Do you have UIDAI Aadhaar No:
Yes
Yes  No
If Yes, Please enter your Aadhaar
No: 819723838988
Do you have Voter ID (EPIC-Election Photo ID Card): Yes
If Yes, Please enter your Voter ID
BFS1863885 Yes  No
No:
Do you have Id (Issued By Central State Government): No
If Yes, Please enter your ID No: Yes  No
Other Address Proof: LIC Policy (125873216)

Optional Details
Bank Name: AXIS
Branch: BALLABHGARH
Address: SEC-7
IFSC Code: UTIB0000039
Account Number: 039010100041715

Declaration: I declare that the information provided by me on the above form 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 not true and incomplete
and also in the event of any violation of Government Regulation related to the supply and distribution of LPG, BPCL
will be well within its right to take necessary action including discontinuation of supply of LPG cylinders, can forfeit
the security deposit and can levy penal charges as per the policy and guidelines. I am willing/not willing to avail the
Subsidy on LPG cylinders therefore I have provided/not provided my Bank account details on the above request
form.

I also confirm that I do not have any objection in receiving SMS from BPCL on the mobile number given in this
form.

Signature of Customer*: Date:

Signature of Distributor*: Date:

-------------------------------------------------Tear Off----------------------------------------------

I/We, hereby, confirm receipt of duly filled in KYC form along with relevant documents of Proof of Identity and
Proof of Address has been received

from ----------------------------------------- on---------------- (date)

Signature and Seal of Distributor