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  • KYC GAs 23 1 13

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    - CONSUMER INFORMATION SHEET (Wait list ID: 1371939) Name of Distributorship: Name Of Consumer Salutation (Mr. / Ms. / Mrs / Miss): First Name : Middle Name: Last Name : Consumer Number: Date of Birth: Father's Name : Mother's Name: Name Of Spouse: Mr. NIHAR ANIL MAYEKAR (Name to be entered as per Photo ID Proof) At least one of the following

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    KYC_GAs_23_1_13

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    - CONSUMER INFORMATION SHEET (Wait list ID: 1371939) Name of Distributorship: Name Of Consumer Salutation (Mr. / Ms. / Mrs / Miss): First Name : Middle Name: Last Name : Consumer Number: Date of Birth: Father's Name : Mother's Name: Name Of Spouse: Mr. NIHAR ANIL MAYEKAR (Name to be entered as per Photo ID Proof) At least one of the following

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    KYC GAs 23 1 13

    Diunggah oleh

    nrmstar
    - CONSUMER INFORMATION SHEET (Wait list ID: 1371939) Name of Distributorship: Name Of Consumer Salutation (Mr. / Ms. / Mrs / Miss): First Name : Middle Name: Last Name : Consumer Number: Date of Birth: Father's Name : Mother's Name: Name Of Spouse: Mr. NIHAR ANIL MAYEKAR (Name to be entered as per Photo ID Proof) At least one of the following

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    Attribution Non-Commercial (BY-NC)
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    dari 2

    CONSUMER INFORMATION SHEET (Wait list ID: 1371939)

    Name of Distributorship: Name Of Consumer* Salutation (Mr./Ms./Mrs/Miss)*: First Name*: Middle Name: Last Name*: Consumer Number: Date Of Birth*: Father's Name*: Mother's Name: Name Of Spouse:

    MR. NIHAR ANIL MAYEKAR (Name to be entered as per Photo ID Proof) (Only for existing customers) 13-03-1986 DD-MM-YYYY ANIL K MAYEKAR KIRAN ANIL MAYEKAR

    Address* (Address to be written as given in Proof of Address) House No*: A-2 House Name/Flat Floor No*: 603 Housing Complex/Building No*: ROSE ICON Street/Road Name*: Area/Land Mark: City/Town/Village*: PUNE District*: PUNE MAHARASHTRA State*: Maharashtra PIN Code*: 411027 Telephone Number: Mobile Number: 9757162362 Email ID: niharmayekar@gmail.com * Mandatory Fields
    At least one of the following documents of Proof of Address is mandatory. Kindly tick the document provided for Proof of Address . Aadhaar (UID) letter . Lease agreement / rent receipt . Telephone/Electricity or any other utility bill . Self-declaration attested by Gazetted officer . Flat allotment/possession letter . LIC Policy . Driving License . Voter ID . Passport . Ration Card . House registration document At least one of the following documents of Proof of Identity is mandatory. Kindly tick the document provided for Proof of Identity . PAN Card . Passport . Voter ID . Aadhaar (UID) letter . Driving License . Central/State Government Issued ID Cards . . . . . -

    CONSUMER INFORMATION SHEET (Page 2)

    Do you have Pan Number: Yes If Yes, Please enter PAN Number: APTPM0627D Do you have a Passport: Yes If Yes, Please enter Passport Number: G3888512 Do you have a Driving License: Yes If Yes, Please enter Driving License No: MH-03/2004/24335 Do you have a Ration Card : No If Yes, Please enter Ration Card No: Do you have UIDAI Aadhaar No: Yes If Yes, Please enter your Aadhaar No: 702045141116 Do you have Voter ID (EPIC-Election Photo ID Card): Yes If Yes, Please enter your Voter ID No: NNX2406718 Do you have Id (Issued By Central State Government): No If Yes, Please enter your ID No: Other Address Proof: Optional Details Bank Name: Branch: Address: IFSC Code: Account Number:

    Physically Verified by Distributor? Yes No Yes No Yes No Yes No Yes No

    Yes No Yes No

    ICICI BANK PIMPLE SAUDAGAR ROSE VALLEY, AUNDH ANNEXE, PIMPLE SAUDAGAR, PIMPRI, PUNE, - 411027. ICIC0001697 056701505334

    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*: Signature of Distributor*: Date: 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

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