CONSUMER INFORMATION SHEET (Wait list ID: 5769494)
Name of Distributorship:

Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*: MR.
First Name*: MD MUSLIM
Middle Name:
Last Name*: ALI
(Name to be entered as per Photo ID Proof)
Consumer Number:
(Only for existing customers)
Date Of Birth*: 17-04-1979
DD-MM-YYYY
Father's Name*: SALIMUDDIN MOMIN
Mother's Name: ANJAMUN BEWA
Name Of Spouse: NAJEMA KHATUN

Address* (Address to be written as given in Proof of Address)
House No*: N0793
House Name/Flat Floor No*: NAJEMA
Housing Complex/Building No*: 742
Street/Road Name*: KAMALPUR
Area/Land Mark: MEHERA PUR
City/Town/Village*: KALIACHAK
District*: MALDA WEST BENGAL
State*: West Bengal
PIN Code*: 732207
Telephone Number:
Mobile Number: 9609821417
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 . -
CONSUMER INFORMATION SHEET (Page 2)
Do you have Pan Number: No Physically
Verified by Distributor?
If Yes, Please enter PAN Number: Yes  No
Do you have a Passport: No
If Yes, Please enter Passport Number:
Yes  No
Do you have a Driving License: No
If Yes, Please enter Driving License No:
Yes  No
Do you have a Ration Card : Yes
If Yes, Please enter Ration Card No:
9688394 Yes  No
Do you have UIDAI Aadhaar No: Yes
If Yes, Please enter your Aadhaar No:
517750765740 Yes  No
Do you have Voter ID (EPIC-Election Photo ID Card): Yes
If Yes, Please enter your Voter ID No: FXV3188190 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 INDIA
Branch: KASHIMBAZAR
Address: KASHIMBAZAR,MALDA
IFSC Code: BKID0004322
Account Number: 432210110012282

Declaration: I 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 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 am willing/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 confirm that I do not have any objection in receiving SMS from BPCL on the mobile number given in this form.

Signature of Customer*:

Date:

Signature of Distributor*:

Date:





-------------------------------------------------Tear Off----------------------------------------------

I/We, hereby, confirm receipt of duly filled in KYC form along with relevant documents of Proof of Identity and Proof of Address has been received

from ----------------------------------------- on---------------- (date)


Signature and Seal of Distributor