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CONSUMER INFORMATION SHEET (Wait List ID: 9348024)

This document is a consumer information sheet for a distributorship of Ebharat Gas. It collects personal information such as name, date of birth, address, identity documentation, and bank account details from the consumer. The consumer declares that the information provided is true and correct. Both the consumer and distributor sign and date the form.

Uploaded by

Rajat Jain
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
101 views

CONSUMER INFORMATION SHEET (Wait List ID: 9348024)

This document is a consumer information sheet for a distributorship of Ebharat Gas. It collects personal information such as name, date of birth, address, identity documentation, and bank account details from the consumer. The consumer declares that the information provided is true and correct. Both the consumer and distributor sign and date the form.

Uploaded by

Rajat Jain
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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CONSUMER INFORMATION SHEET (Wait list ID: 9348024) Name of Distributorship: Name Of Consumer* Salutation (Mr./Ms./Mrs/Miss)*: First Name*: Mi""le Name: #ast Name*: Consumer Number: Date Of -irth*: Father5s Name*: Mother5s Name: Name Of Spouse:

MRS SAND !A $%&'A (Name to be entere" as per &hoto (D &roof) (Onl) for e*istin+ ,ustomers) ./01/0.234 DD0MM0!!!! -R(6 7(S OR8 $%&'A 7AM#8S $%&'A RA6A' 6A(N

A""ress* (A""ress to be 9ritten as +i:en in &roof of A""ress) ouse No*: ;/.<. ouse Name/Flat Floor No*: S8COND F#OOR ousin+ Comple*/-uil"in+ No*: =(- A= 7 AND Street/Roa" Name*: $OM'( NA$AR Area/#an" Mar>: ON8!MAN C O?7 Cit)/'o9n/=illa+e*: #%C7NO? Distri,t*: #%C7NO? %''AR &RAD8S State*: %ttar &ra"esh &(N Co"e*: <</.14 'elephone Number: Mobile Number: 3;1111<1@@ 8mail (D: "r.san"h)a+uptaAli:e.,om * Man"ator) Fiel"s
At least one of the follo9in+ "o,uments of &roof of A""ress is man"ator). 7in"l) ti,> the "o,ument pro:i"e" for &roof of A""ress . Aa"haar (%(D) letter . #ease a+reement / rent re,eipt . 'elephone/8le,tri,it) or an) other utilit) bill . Self0"e,laration atteste" b) $aBette" offi,er . Flat allotment/possession letter . #(C &oli,) . Dri:in+ #i,ense . =oter (D . &assport . Ration Car" . ouse re+istration "o,ument At least one of the follo9in+ "o,uments of &roof of ("entit) is man"ator). 7in"l) ti,> the "o,ument pro:i"e" for &roof of ("entit) . &AN Car" . &assport . =oter (D . Aa"haar (%(D) letter . Dri:in+ #i,ense . Central/State $o:ernment (ssue" (D Car"s . 0 . 0 . 0 . 0 . 0

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CONSUMER INFORMATION SHEET (Page 2) Do you have Pan Number: Yes If Yes, Please enter PAN Number: AXSP !""#$ Do you have a Pass%ort: No If Yes, Please enter Pass%ort Number: Do you have a Drivin& 'icense: No If Yes, Please enter Drivin& 'icense No: Do you have a (ation $ard : No If Yes, Please enter (ation $ard No: Do you have )IDAI Aadhaar No: No If Yes, Please enter your Aadhaar No: Do you have Voter ID *+PI$,+lection Photo ID $ard-: Yes If Yes, Please enter your Voter ID No: 'PY./0.1!1 Do you have Id *Issued 2y $entral State overnment-: No If Yes, Please enter your ID No: 3ther Address Proof: Self,declaration attested by 3%tional Details 2an7 Name: 2ranch: Address: I5S$ $ode: Account Number: Declaration: I declare that the information %rovided by me on the above form is true and correct to the best of my 7no8led&e and belief9 I also confirm that in the event of any information %rovided by me is not true and incom%lete and also in the event of any violation of overnment (e&ulation related to the su%%ly and distribution of 'P , 2P$' 8ill be 8ell 8ithin its ri&ht to ta7e necessary action includin& discontinuation of su%%ly of 'P cylinders, can forfeit the security de%osit and can levy %enal char&es as %er the %olicy and &uidelines9 I am 8illin&:not 8illin& to avail the Subsidy on 'P cylinders therefore I have %rovided:not %rovided my 2an7 account details on the above re;uest form9 I also confirm that I do not have any ob<ection in receivin& S=S from 2P$' on the mobile number &iven in this form9 Signature o Cu!to"er#: Signature o Di!tri$utor#: Date: Date: Physically Verified by Distributor? Yes No Yes No Yes No Yes No Yes No

Yes No Yes No a4etted officer *S+'5 D+$'A(A6I3N-

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Tear O %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% I:>e, hereby, confirm recei%t of duly filled in ?Y$ form alon& 8ith relevant documents of Proof of Identity and Proof of Address has been received from ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, on,,,,,,,,,,,,,,,, *dateSignature an& Seal o Di!tri$utor

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