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    KYC - BharatGas

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    ashok.ram984868

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    © All Rights Reserved
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    KYC - BharatGas

    Uploaded by

    ashok.ram984868
    5 views2 pages

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    5 views2 pages

    KYC - BharatGas

    Uploaded by

    ashok.ram984868

    Copyright:

    © All Rights Reserved
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    11/2/24, 4:47 PM KYC - BharatGas

    Know Your Customer (KYC) Form (Request ID: 90814330)


    1) Personal Details
    Name Of Consumer* Paste your photograph here
    Salutation (Mr./Ms./Mrs/Miss)*: MS.
    First Name*: SOLLU
    Middle Name:
    Last Name*: RUKHMINI
    Date Of Birth*: 10-06-2000
    Gas Consumer Number:
    (Only for existing customers) (DD-MM-YYYY)

    Name of Distributorship: SHIVA BHARATGAS AGENCIES ( 188249 )


    Father's Name*: SOLLU ESWARAIAH Spouse Name : MADIGA ASHOK
    Mother's Name: SOLLU SHANTHAMMA
    2) Address for LPG connection / Contact Information
    Proof Of Address (POA)
    POA Category: 9 - Aadhaar (UID) POA Detail: 472955395457
    House/Flat#, Name : 76-97-387- Floor No : 2
    Land Mark : NEAR GOVT PRIMARY
    Housing Complex/Building : SAMPATHI MADDILETI NAGAR
    SCHOOL
    Street/Road Name : NTR NAGAR
    City/Town/Village: KURNOOL
    PIN Code: 518003
    District : KURNOOL State : ANDHRA PRADESH
    Mobile No : 7569756884 Landline :
    Email ID: ashokdeva1999@gmail.com
    3) Other Relevant Details
    Proof Of Identity (POI)
    POI Category: 9 - Aadhaar (UID) Card Number: 472955395457
    Ration Card Details if Available
    State Of Issue: Ration Card Number:
    4) Bank Details
    BankName: Kotak Mahindra Bank Ltd IFSC/MICR/INN: KKBK0007889
    Account Type: Saving Account No: 2645575820
    Name As In Account: RUKHMINI SOLLU

    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
    Date:
    SHIVA BHARATGAS AGENCIES

    https://my.ebharatgas.com/bharatgas/LPGServices/PrintForm 1/2
    11/2/24, 4:47 PM KYC - BharatGas

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

    Signature and Seal of Distributor

    https://my.ebharatgas.com/bharatgas/LPGServices/PrintForm 2/2

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