Know Your Customer (KYC) Form (Wait list ID: 5769494)
1) Personal Details
Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*: MR.
First Name*: MD MUSLIM
Middle Name:
Last Name*: ALI
Gas Consumer Number:  
(Only for existing customers)
Date Of Birth*:    17-04-1979 
(DD-MM-YYYY)
Name of Distributorship: JAYASREE GAS AGENCY ( 127548 )
Father's Name*: SALIMUDDIN MOMIN Spouse Name :     NAJEMA KHATUN
Mother's Name: ANJAMUN BEWA
2) Address for LPG connection / Contact Information
Proof Of Address (POA)
POA Category: - POA Detail:   
House/Flat#, Name : N0793 Floor No :   NAJEMA
Housing Complex/Building : 742 Land Mark :   MEHERA PUR
Street/Road Name : KAMALPUR
City/Town/Village: KALIACHAK PIN Code:   732207
District : MALDA WEST BENGAL State :   West Bengal
Mobile No : 9609821417 Landline :   
Email ID:
3) Other Relevant Details
Proof Of Identity (POI)
POI Category: - Card Number:   
Ration Card Details if Available
State Of Issue: Ration Card Number:   9688394

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

I also confirm that I do not have any objection in receiving SMS from BPCL on the mobile number given in this form.

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
JAYASREE GAS AGENCY

Date:

-------------------------------------------------Tear Off----------------------------------------------
I/We, hereby, confirm receipt of duly filled in KYC form along with relevant POI, POA documents form
Name  MR. MD MUSLIM   ALI    Consumer no (if applicable)  on____________________ (date)

Signature and Seal of Distributor