UNDERTAKING FOR LOSS OF LPG PRESSURE REGULATOR/CYLINDER

I, _________________________________ son/daughter/wife of Shri _____________________

aged _____ years, Resident of ____________________________________________________

and Indian inhabitant do hereby solemnly affirm and declare as follows:

1. That I am a consumer of HPGAS with Customer No. __________ being served through

their distributor M/s. ________________________________________ since ________.

2. That I have lost the LPG Pressure Regulator/Cylinder on ____________ (date), involving

_________________________________________________________(reasons for loss).

3. That I have neither given the pressure regulator / cylinder to any other person nor used it

for any purpose against the guidelines issued by HPCL.

4. That I shall be liable to any action taken by M/s. HPCL in case this claim for loss of

Pressure Regulator/cylinder is proved to be false, or it is found that I am involved in

illegal use of the pressure regulator/cylinder.

5. That I undertake to return forth with the above referred pressure regulator/cylinder to

M/s. Hindustan Petroleum Corporation Ltd., if found at any time.

SIGNED ________________________
(Signature of the Customer)
Place:
Dated:

IN THE PRESENCE OF:

1. ____________________

2. ____________________