M/S __________________________________________
Know Your Customer(KYC) Form
(To be filled in black ink with BLOCK LETTERS by consumer while registering for LPG Gas connection
* are mandatory)

1. Customer Details *
a. Name shall be entered as per Photo ID Proof)
(Mr./Ms./Mrs/Miss/Dr) *
b. Gas Consumer Number
(Mandatory for existing customers)
c. Date of Birth*
2. Details of Close Relatives
a. Father’s Name*
b. Mother’s Name
c. Name of Spouse
3. Proof of address (POA) (At least copy of one of the following documents listed below is to be attached/scanned with this form. Consumer is required to produce the original of document for verification by the distributor, when sought for. Kindly tick the POA provided by you below and fill up address details in S.No. 4 below accordingly)
Aadhaar (UID) Driving License
Lease agreement Voter ID
Telephone/Electricity /Water bill Passport
Self-declaration attested by a Gazetted officer. Ration Card
Flat allotment/possession letter House registration document
LIC Policy Bank/Credit Card Statement
4. Connection Address/Contact Information* (Address should be written as per Proof of Address)
First Name*
Middle Name
Last name*
D
D
M
M
Y
Y
House # *
House Name/Flat Floor #
Housing Complex/Building #
Street/Road Name
City/Town/Village *
District *
State *
PIN Code *
Furnish here any other address related Information which is not in the Proof of Address, but will help locate the house (Floor, landmark etc)
Paste your photo here
Email
5. Proof of Identity (POI) ( Serial numbers of all POIs you hold should be provided. At least copy of one of the following PHOTO ID document MUST be attached /scanned with this KYC, which should be VALID and should be ticked in last column. This POI in original is required to be produced for verification by the distributor when sought for.)
6. Ration Card : ( In case your name is appearing in any ration card issued by the State Government please provide
the card number
and the
Name of the State
Government )
7. Optional Bank
Account details ( Fill if you desire the notified subsidy to be transferred to your bank account as and when conditional direct transfer of subsidy commences – in that case please give a copy of cancelled cheque also)
a. Bank Name
b. Branch & Address
c. IFSC Code
d. Bank Account Number
Declaration: I hereby declare that the information provided by me on the above form 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 not true/ is incomplete and also in the event of any violation of Government Regulation related to the supply and distribution of LPG, the OMC will be well within its right to take necessary legal action including discontinuation of supply of LPG cylinders to me, forfeiture of my security deposit, and levy of penal charges as per the policy and guidelines.
I am willing/not willing to avail the Subsidy on LPG cylinders, in event of direct conditional transfer of cash subsidy, and therefore have provided/not provided my Bank account details above (strike off not applicable)
Name & Signature of Customer Date:
To be filled by Dealer/Distributor
Consumer Number (If allotted): Date:
Signature of Distributor
------------------------------------------------------------------Tear Off--------------------------------------------------------------------------------------
I/We, hereby, confirm receipt of duly filled in KYC form along with copy relevant documents of Proof of Identity and Proof of
Address from (consumer#) ----------------------------------------- on dated---------------- Signature and Seal of Distributor
Contact Number (landline)
Mobile Number
@
POI Type
Issuing Authority (Mention)
ID Card Number
Tick if attached
Aadhaar Number (UID/EID)
UIDAI
Passport Number
RPO
PAN Card Number
GOI
Voter ID Card
ID card Issued By Central/State
Driving License
State of Issue
Card Number