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    Self Dec

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    anannyaonlinecenter

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    © All Rights Reserved
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    Self Dec

    Uploaded by

    anannyaonlinecenter
    5 views1 page

    Original Title

    SELF DEC

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    © © All Rights Reserved

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    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    5 views1 page

    Self Dec

    Uploaded by

    anannyaonlinecenter

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    NC-TV Declaration format Ver.

    1-BpC/14

    Format fcr Declaratlon


    (To be submitted by persons desirous of New LPG Connection or connection against rermination Voucher)

    Declaration

    of
    Llnc{ nl(Ogr &ltt)
    F
    n/' ughter, of
    etr u M- .years, resident
    b-

    deslre to take domestic LpG


    connection in my name and affirm as under:

    L' That I am an lndian citizen/Non Resident indian /staff of Foreign nationaiity


    serving in inciia/ Foreign nationai
    residing in lndia under valid visa / person returning to lndia on transfer
    of residence basis/ plo
    *Tiek whiehever
    is applieable= ladiun citizens are eligible subsidized LpG.far
    2. That my date of birth is connection cannot be orovided to a person under 1g vears of age)
    (LPG
    3. That neither l, nor any h r member of the household (househord means a family consisting of husband,
    rvife, unmarried ch!lCren a nd dependent pa!'ents livlng together in a du;elling unit having common kitchen),
    possess any LPG connect! on from PSU oi! companies or piped Natural Gas connection foi. domestic
    use in our
    dwelling unit. ('Households' having Piped Natural Gas connection ore not
    entitled for Subsidized LpG)
    4. @That t am enclosing a copy of Ration card nunber{2jTZD\ -y'L, includir-rg my
    name
    Qr 969ga
    @That I do not have Ration card in my name of in the nrr" oi.ny member of my ,household,
    as defined
    abo're' '4s and when a ration card is issued in lrly nafile sr in the name
    cf any of the members af the
    'household', the same shal! be produced to oil company LpG distributor-
    for updating records.
    @Delete, whichever is not applicable
    5' That I am encicsing the KYC form duly filled in along with the proof cf Address
    ipoA.i and prcof cf ldentity(pol)
    6' I confirm that the LPG connection issued to me rryill be used
    in my above mentioned address and for domestic
    cooking purpose only and I shall abide by all terms governing its use.
    7. That I shali not position any other Lp gas installations in the same kitcher.r
    8' That as and when second eylinder is issued to me against this eonnection
    the same will alss be used in the
    same kitcherl and with the original installation.
    9' That whene'rer I change rny r-esidence fronr present address to another,
    I will infornr M/s.
    {Name of Distributors/RGGlv) in writtng in advance for change of
    address in the records
    10' That I em a\,'-'are that the domestic subsidized LFG connecticn as shall be r"eleased by M/s. lndia* cil
    Corporation (!OCL) Bharat petr.oleum Corporation (BPCL) I Hindustan pptroleum Co!.po!.ation (HpCL)
    / on the
    basis of this declaration and information submitted by me in the Know your
    customer (Kyc) form, proof of
    Address and Proof of ldentity, shall later be subjected to ce-duplicaticn
    check for existence of any cther
    domestic subsidlzed LpG connection with anrT govt. Oil Company, in my name
    or in the name of any other
    member of my'household' as at para .3, above.
    i1' That if any infori'aation ./ declaration given by me in this undertaking, the ,.1$C, form or any docun:ent
    submitted in suppot't of identity / r"esidence proof shall be found untrue
    or ineorrect or false, the oil company
    would be within its rights to withdraw the supply of Gas/Terminate the connectionl
    seize the equipments /
    forfeit the secur"ity deposit and that I would have no clairn whatsoe'.,er against
    locl/ BpcL/ HpCL for such
    withdrawal/ Ter.mination ,/ Seizure / Forfeitur.e.

    I hereby declare that whatever has been stated above of my knowledge, correct and nothing
    nlatei'ia! has been concealed there frorn

    Date: > C)6 lo LLl Sign e Declaration

    P!ace Nam D\ Cc*t\ ,ltt<

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