Know Your Customer (KYC) Form (Wait list ID: 80285)
1) Personal Details
Name Of Consumer*
Salutation (Mr./Ms./Mrs/Miss)*: MR.
First Name*: DEEPAK
Middle Name: PITAMBAR
Last Name*: PATIL
Gas Consumer Number:  
(Only for existing customers)
Date Of Birth*:    06-11-1982 
(DD-MM-YYYY)
Name of Distributorship: B.K. ENTERPRISES ( 112338 )
Father's Name*: PITAMBAR Spouse Name :     REVATI
Mother's Name: NABABAI
2) Address for LPG connection / Contact Information
Proof Of Address (POA)
POA Category: - POA Detail:   
House/Flat#, Name : 386 Floor No :   NA
Housing Complex/Building : NA Land Mark :   CHANDANNAGAR
Street/Road Name : PRAKASHBAPU PATHARE NAGAR
City/Town/Village: KHARADI PIN Code:   411014
District : PUNE MAHARASHTRA State :   Maharashtra
Mobile No : 9028697892 Landline :   9028697892
Email ID: deepak_patil@jabil.com
3) Other Relevant Details
Proof Of Identity (POI)
POI Category: - Card Number:   
Ration Card Details if Available
State Of Issue: Ration Card Number:   

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
B.K. ENTERPRISES

Date:

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

Signature and Seal of Distributor