Application Format For Individual Applicants

Application No. H P C 1 6 9 5 6 5 2 1 0 5 1 3 2 9

Application Date ** 2 5 - 0 9 - 2 0 2 3
APPLICATION FOR RETAIL OUTLET DEALERSHIP
Name of oil company Hindustan Petroleum Corporation Ltd.
Name of Regional Office KANPUR
Particulars of application fee (Rs.) 3,000.00
Transaction Number 0607630453437
Transaction Date & Time 25-09-2023 21:05:16
Payment Mode UPI
Are you dealer of an unviable# SKO Dealership (# Not Applicable
as per clause 4 (ix) (i) of brochure)?
Particulars of Applied location
1 Sr. No. of location in the advertisement 467
2 Name of the Location FROM BETWA BRIDGE TO JUNIOR HIGH SCHOOL
KUNDAURA, ON NH-34 (OLD NH-86) ON KANPUR-
KABRAI HIGHWAY
3 District H A M I R P U R
4 State U T T A R P R A D E S H
5 Category S C
Eligibility certificate(s) for the category applied as above is/are available with me/us and will be submitted as and when advised by the Hindustan Petroleum Corporation Ltd..
6 Advertised on 28-June-2023 In List of advertised locations in Uttar Pradesh_ English,
UP_DAINIK JAGRAN_HINDI_28.06.23,
UP_TIMES OF INDIA_ENGLISH_28.06.23
7 Type of Site CFS
8 Type of RO Regular
9 Group of the Applicant on the Basis of land being Group 1
offered.
10 Type of applicant Proprietor
11 Applicant would be required to submit Affidavit in original as per the format given in Appendix – XA of the Brochure on intimation
by Hindustan Petroleum Corporation Ltd. upon selection.
11.1 Name Mr. ASHISH Verma
11.2 Father’s / Husband’s Name Mr. SIDDHA GOPAL
11.3 Address 278, PANDHARI SUMERPUR RURAL
District HAMIRPUR State UTTAR PRADESH Pincode 210502
Tel No. 9140805080 Mobile No. * 8303519155
Email ID * ashishverma311311311@gmail.com
PAN BZOPV2411A
11.4 Indian Citizen Yes Resident of India as per IT Rules Yes
11.5 Gender Male
11.6 Date of Birth 12-March-2002 Age 2 1 years 0 6 months 1 3 days
Proof of age required to be submitted as and when asked by Hindustan Petroleum Corporation Ltd.
11.7 Document Relied for 10th Standard Board Certificate
proof of Age
11.8 Marital Status Single
11.1 Are you employeed in Private Sector or drawing No
1 any salary/perks/emoluments from State / Central
Goverment ?
12 Applicants Education Qualification (Minimum 10th pass or equivalent) Proof of qualifying certificate as per Eligibility criteria would
be required to be submitted as and when asked by Hindustan Petroleum Corporation Ltd.)
Qualification Name of Board/University/Institution Certificate/Diploma/Deg Year of Passing
ree
12.1 10th Pass or equivalent CBSE 2017
12.2 Graduation BBA DEGREE 2023
13 Land details - Group 1 ( Copy of proof of ownership of land would be required to be submitted as and when advised by Hindustan
Petroleum Corporation Ltd.)
Name(s) of the Relationship Date of Location of the Khasra No/Kha Dimensions of land
owner of Land / with applicant registration of land with touni/Gut Frontage in Depth in metre Area (Sq.m)
Lease holder sale deed/gift respect to No/Survey No metre
deed / lease Reference point
deed/ date of / Land mark
mutation/ date (Specify land
of Notarized mark /
Affidavit for Reference point
offer of land as and distance
per Appendix from the same)
III
Plot No. 1
SIDDHA FATHER 13-09-2023 Village 00161/337 40.00 40.00 1600.00
GOPAL Chandoukhi
NH-34 Distric-
Hamirpur UP
Are you willing to transfer the land on sale/long lease to Hindustan Petroleum Corporation Ltd. Yes
If yes, at what rate(Rs.) / terms. 30000
The above piece of plot owned by me/my family member (as defined in Clause 4(vi) h of Brochure) either by way of ownership / long term
lease, would be made available for a period as per the terms and condition of the advertisement published by the the Oil Company Hindustan
Petroleum Corporation Ltd..
That as per the documents available with me/us, my/our offer qualifies for being considered under "GROUP 1" as defined in Clause 4 (vi) of
the Brochure for retail outlet dealer selection by the Oil Company Hindustan Petroleum Corporation Ltd..
The said land, has been offered for purchase / lease / sub-lease to the oil company for a period as per the terms and condition of the advertisement published by
the Oil company Hindustan Petroleum Corporation Ltd.
Note: In case land belongs to member of Family / Co-owners / Others, before submission of application, notarized affidavit as per Appendix - III
should be available with the applicant, which is to be uploaded/submitted as and when asked by Oil Company Hindustan Petroleum Corporation
Ltd.
In Case the offered land has multiple Khasra / Khatauni / Gut / Gatta / Patta / Plot / Survey Nos. etc., complete details of land to be entered in the
application.
The Site map/Layout sketch (as indicated in Appendix - V of the Brochure) indicating dimensions/ area pertaining to the part/portion of the total land where Retail
Outlet is propsed to be developed, will be uploaded by me as and when advised by Oil Company Hindustan Petroleum Corporation Ltd.
14 Requirement of Finance: Not Applicable
15 UNDERTAKING BY THE APPLICANT
a. I am aware that eligibility for Retail Outlet Dealership will be decided based on the information given in the application above. On verification by the Oil
Company Hindustan Petroleum Corporation Ltd. if it is found that the information given by me is incorrect/ false/ misrepresented then my candidature
will stand cancelled and I will be declared ineligible for the Retail Outlet Dealership.
b. I also confirm that I am in possession of the supporting documents in original in respect of the information given by me in this application and if selected,
failure to present these documents in original will result in cancellation of selection due to submission of false/unsupported information in this application.
c. I am fully aware that if I am unable to provide suitable site mentioned above for setting up of the Retail Outlet as per the Oil Company' s standard layout,
then the offer / allotment of dealership made to me will be cancelled.
d. I am fully aware that I will not be appointed as Retail Outlet Dealer if I am employed. I shall have to resign from the service and produce proof of
acceptance of my resignation from my employer before issuance of Letter of Appointment.
e. I am also aware that I cannot take up any other employment nor can draw any salary/perks/emoluments from State/Central Government upon my
appointment as a dealer.
f. I confirm that neither I nor any member of my "family unit" (as per definition of family under multiple dealership norm given in Brochure) are employees
of Indian Oil Corporation Ltd or Bharat Petroleum Corporation Ltd or Hindustan Petroleum Corporation Ltd.
g. I am fully aware that If selected I shall be paying attention towards day to day working of the dealership by personally managing the affairs of the
dealership and will not be eligible for taking up any employment.
h. I undertake to fulfill the conditions of Hindustan Petroleum Corporation Ltd. with regard to inducting Spouse as Co-owner in the dealership if the
dealership is awarded to me.
i. That, if selected, I undertake that I will be depositing an interest free Security deposit of Rs. 300,000.00 as per the policy of the Corporation.
j. I am also aware that the same land cannot be offered by more than one applicant for a particular RO location against the same advertisement. In case it is
found that the same piece of land as offered by me has been offered by other applicant(s) for this location then my candidature for RO dealership will be
rejected/ Dealership terminated, if already appointed.
k. I confirm that I am of sound mental health & I am not totally paralyzed.
l. I confirm that I have never been convicted for any criminal offence involving moral turpitude and/or economic offences (other than freedom struggle).
m. I hereby confirm that neither I nor any member of my Family Unit (as defined under Multiple dealership norm for individuals/non-individuals of
Disqualification criteria), was ever a signatory to dealership/distributorship agreement of any Oil Company, which was terminated for proven malpractices
and / or for violations of provisions of the Marketing Discipline Guidelines.
n. I do hereby confirm that I am eligible for allotment of Retail Outlet dealership as per applicability of Multiple Dealership Norm defined under Clause
 Disqualification in the Brochure for Selection of Dealers for Regular & Rural Retail Outlets and do not disqualify for allotment of Retail Outlet dealership
under other conditions mentioned therein.
o. I hereby confirm that my candidature has never been rejected/selection cancelled/dealership or distributorship terminated by any of the Oil Company for
providing false information/misrepresentation of facts/submitting false/fake documents while applying for RO/SKO-LDO Dealership / LPG
Distributorship
p. I confirm that the mobile no., e-mail Id, PAN and address mentioned in this application form belongs to me.
q. I am aware that this is only a business offer and the oil company. reserves the right to cancel the advertised location and I shall not claim any
damages/compensation from the oil company.

Declaration

I, ASHISH VERMA son of Shri SIDDHA GOPAL hereby confirm that the information given above is true and correct. Any wrong information
/misrepresentation/ suppression of facts will make me ineligible for this RO dealership. That if any information/declaration given by me in my
application or in any document submitted by me in support of application for the award of the RO dealership shall be found to be untrue or incorrect or
false, the Hindustan Petroleum Corporation Ltd. would be within its rights to withdraw the letter of intent / terminate the dealership (if already
appointed) and that I would have no claim, whatsoever, against the Corporation for such withdrawal / termination.

Signature of applicant

**Date : 2 5 - 0 9 - 2 0 2 3 Name of applicant ASHISH VERMA

**The date mentioned in the application will be treated as date applicable for the purpose of evaluating the eligibility criteria.
Note:* All further communication will be done on registered email address & mobile number.

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