Know Your Customer (KYC) Form

1) Personal Details

Title*

First Name*

Middle Name

Last Name*

Gas Consumer Number*

Date of Birth* (DDMMYYYY)

Close Relative

Father's / Spouse Name*

Mother's name*

2) Address for LPG connection / Contact Information

Proof of Address (POA) category Code*

House/Flat #, Name*

Floor No*

Housing Complex/Building

Land Mark

Street/Road Name

City/Town/Village*

District*

State*

Pin Code*

Phone #*: Mobile No

Landline #

Email id

3) Other Relevant Details

Proof of Identity (POI) Category Code*

Card Number*

Ration Card Details (if Available)

State Of Issue

Ration Card Number

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, IOC/BPC/HPC will be within its right to discontinue supply of LPG cylinders to me, forfeit of security deposit and levy of penal charges as per the policy and guidelines and may initiate legal action applicable under provisions.

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

Acknowledgement

I/We, hereby, confirm receipt of duly filled in KYC form along with copy relevant POI, POA documents from Name on Consumer no (if applicable)

Field

Guideline

1 a) Name

Name to be entered as given in Photo ID Proof. Fields marked with * are mandatory.

1 b) Gas Consumer Number

Mandatory for consumers already using LPG from IOC/BPC/HPC.

1 d) Details of Close Relative

Father or Spouse name is mandatory. Please strike off whichever is not applicable.

2) Proof Of Address (POA)

At least one of the documents listed below should be attached and the category code mentioned in the form. The Address must be entered exactly as it appears in the POA. Produce the original for verification.

Aadhaar (UID)	POA01
Driving License	POA02
Lease agreement	POA03
Voter ID	POA04
Telephone/Electricity/Water bill	POA05
Passport	POA06
Self-declaration attested by a Gazetted officer	POA07
Ration Card	POA08
Flat allotment/possession letter	POA09
House registration document	POA10
LIC Policy	POA11
Bank/Credit Card Statement	POA12

3 a) Proof of Identity (POI)

At least one of the documents listed below should be attached and the category code mentioned in the form. Produce the original for verification.

Aadhaar Number (UID/EID)	POI01
Passport Number	POI02
PAN Card Number	POI03
Voter ID Card	POI04
ID card Issued By Central/State	POI05
Driving License	POI06