CONSUMER INFORMATION SHEET

Name of Distributorship: GAURI GAS DISTRIBUTORS

Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*: MR.
First Name*: J ITENDRA
Middle Name: RAMBHAU
Last Name*:
PATIL
(Name to be entered as per Photo ID
Proof)
Consumer Number:
46566257
(Only for existing customers)
Date Of Birth*:
06-06-1985
DD-MM-YYYY
Father's Name*: RAMBHAU
Mother's Name: PARWATIBAI
Name Of Spouse: SANGITA
Address* (Address to be written as given in Proof of Address)
House No*: 150
House Name/Flat Floor No*:
Housing Complex/Building No*:
Street/Road Name*: VASAI ROAD
Area/Land Mark: VAJ RESHWARI
City/Town/Village*: GANESHPURI
District*: THANA MAHARASHTRA
State*: Maharashtra
PIN Code*: 401206
Telephone Number:
Mobile Number: 9049367895
Email ID:
* Mandatory Fields
At least one of the following documents of Proof of Address is
mandatory. Kindly tick the document provided for Proof of Address
At least one of the following documents of Proof of Identity is
mandatory. Kindly tick the document provided for Proof of 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 . -
KYC - Bharatgas http://www.ebharatgas.com/ebgas/faces/KYC_Print.jsp?p1=print
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CONSUMER INFORMATION SHEET (Page 2)
Do you have Pan Number: Yes
Physically
Verified by Distributor?
If Yes, Please enter PAN Number: BITPP5153K Yes No
Do you have a Passport: No
If Yes, Please enter Passport Number:
Yes No
Do you have a Driving License: Yes
If Yes, Please enter Driving License No: MH0420110056454
Yes No
Do you have a Ration Card : No
If Yes, Please enter Ration Card No:
Yes No
Do you have UIDAI Aadhaar No: Yes
If Yes, Please enter your Aadhaar No: 383246901972
Yes No
Do you have Voter ID (EPIC-Election Photo ID Card): Yes
If Yes, Please enter your Voter ID No: SNL2601714 Yes No
Do you have Id (Issued By Central State Government): No
If Yes, Please enter your ID No: Yes No
Other Address Proof:
Optional Details
Bank Name: BANK OF MAHARASTRA
Branch: GANESHPURI
Address: BHIWANDI
IFSC Code: MAHB0000198
Account Number: 60112019735
Declaration: I declare that the information provided by me on the above formis true and correct to the best of my knowledge and
belief. I also confirmthat 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 amwilling/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 confirmthat I do not have any objection in receiving SMS fromBPCL on the mobile number given in this form.
Signature of Customer*: Date:
Signature of Distributor*: Date:
-------------------------------------------------Tear Off----------------------------------------------
I/We, hereby, confirmreceipt of duly filled in KYC formalong with relevant documents of Proof of Identity and Proof of Address
has been received
from----------------------------------------- on---------------- (date)
Signature and Seal of Distributor
KYC - Bharatgas http://www.ebharatgas.com/ebgas/faces/KYC_Print.jsp?p1=print
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