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Know Your Customer (KYC) Form
*Mandatory Fields
Only A-Z, a-z, 0-9, Comma (,), Hyphen (-) and Slash (/) are allowed. No other special character is allowed in any entry field.
Request For New Connection
1) Personal Details
Salutation
*
:
--Select--
Mr.
Ms.
Mrs.
Miss
First Name
*
:
Middle Name:
Last Name
*
:
Date Of Birth
*
:
(DD-MM-YYYY)
Close Relative
Father's Name
*
:
OR
Spouse Name
*
:
Mother's Name
*
:
2) Address for LPG connection / Contact Information
Proof of Address ( POA )
click here to know list of accepted documents
POA Category
*
:
-Select-
Passport
Voter ID
Ration Card
Driving License
House Registration document
Aadhaar (UID)
Lease Agreement
Telephone/Electricity /WaterBill
Self Declaration attested by Gazette officer
Flat allotment /possession letter
Insurance Policy
BanK/Credit Card/Passbook/Post Office Account Statement
POA Detail
*
:
House / Flat #, Name
*
:
Floor No
*
:
Housing Complex/Building
*
:
Street/Road Name
*
:
Land Mark
*
:
City/Town/Village
*
:
State
*
:
-Select-
Andaman & Nicobar Is
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadar & Nagar Have
Daman & Diu
Delhi
Goa
Gujarat
Goa
Haryana
Himachal Pradesh
Jammu & Kashmir
Jharkand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry & Mahe
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttrakhand
West Bengal
District
*
:
-Select-
ARIYALUR
CHENGALPATTU
CHENNAI
COIMBATORE
CUDDALORE
DHARMAPURI
DINDIGUL
ERODE
KALLAKURICHI
KAMARAJAR
KANCHEEPURAM
KANYA-KUMARI
KARUR
KRISHNAGIRI
MADURAI
MAYILADUTHURAI
NAGAPATTINAM
NAMAKKAL
NEGEL Q MILLIETH
PERAMBALUR
PUDUKKOTTAI
RAMANATHAPURAM
RANIPET
SALEM
SIVAGANGA
TENKASI
THANJAVUR
THE NILGIRIS
THENI
TIRUNELVELI
TIRUPATHUR
TIRUPPUR
TIRUVALLUR
TIRUVANNAMALAI
TIRUVARUR
TRICHIRAPALLI
TUTICORIN
VELLORE
VILUPPURAM
VIRUDHUNAGAR
Distributor:
-Select-
ABR GAS AGENCIES
AKILAA BHARATGAS GRAMIN VITRAK
BANU GAS AGENCY
CHANDRIKA BHARATGAS AGENCY
DIVYAMALAR BHARAT GAS AGENCY
HARI BHARATGAS AGENCY
JAI BHARATGAS AGENCY
K.J. GAS AGENCIES
K.RAMANAIAH BHARATGAS AGENCY
KANAGASABAI BHARATGAS AGENCY
KANNIGA GAS AGENCIES
LEEMA BHARATGAS AGENCY
OM BHARATGAS
PAPPA GAS AGENCY
PARIVAR KALYAN GAS AGENCY
PONNERI BHARATGAS AGENCY
RAJNI GAS AGENCY
RAN BHARATGAS GRAMIN VITRAK
SHIRDI SHREE SAI BABA
SHREE BHAVAANI BHARATGAS AGENCY
SHRI SAIRAM BHARATGAS SERVICES
SHRI SATHYA SAI GAS SERVICE
SREE MEENAKSHI BHARATGAS AGENCY
SREE MURUGAN GAS AGENCY
SRI BALAJI BHARATGAS GRAMIN VITRAK
SRI GOPI BHARATGAS AGENCY
SRI JAYADEVI BHARATGAS AGENCIES
SRI KAVISH BAHARATGAS AGENCY
SRI MAHALAKSHMI BHARATGAS GRAMIN
SRI SAI VINAYAGA BHARATGAS AGENCY
SRI VASAVI BHARATGAS GRAMIN VITRAK
SRI VENKATESH BHARATGAS AGENCY
STAR BHARATGAS AGENCY
TDCCWS BHARATGAS AGENCY
VELMURUGAN BHARATGAS GRAMIN VITARAK
VINAYAGA BHARATGAS GRAMIN VITRAK
Pin Code
*
:
-Select-
600019
600037
600049
600050
600051
600052
600053
600054
600055
600056
600057
600058
600060
600062
600065
600066
600067
600068
600071
600072
600076
600077
600087
600095
600098
600099
600103
600107
600110
600120
600123
600124
600128
601101
601102
601103
601201
601202
601203
601204
601205
601206
602001
602002
602003
602021
602023
602024
602025
602026
602105
631201
631202
631203
631204
631205
631206
631207
631208
631209
631210
631211
631212
631213
631301
631302
631303
631304
631402
Mobile Number
*
:
Telephone Number
(With STD Code without prefixing '0'):
Email ID
*
:
3) Other Relevant Details
Proof of Identity ( POI )
click here to know list of accepted documents
POI Category
*
:
-Select-
Passport
Voter ID
Driving License
Aadhaar (UID)
PAN CARD Number
ID card Issued By Central /State
Card Number
*
:
Ration Card Details if Available:
State Of Issue for Ration Card:
-Select-
Andaman & Nicobar Is
Andhra Pradesh
Arunachal Pradesh
Assam
Bihar
Chandigarh
Chhattisgarh
Dadar & Nagar Have
Daman & Diu
Delhi
Goa
Gujarat
Goa
Haryana
Himachal Pradesh
Jammu & Kashmir
Jharkand
Karnataka
Kerala
Lakshadweep
Madhya Pradesh
Maharashtra
Manipur
Meghalaya
Mizoram
Nagaland
Orissa
Pondicherry & Mahe
Punjab
Rajasthan
Sikkim
Tamil Nadu
Telangana
Tripura
Uttar Pradesh
Uttrakhand
West Bengal
Ration Card Number:
4) Details Related to Cash Transfer
Government has launched the
'Give Up Subsidy'
scheme which is aimed at motivating LPG users who can afford to pay the market price for LPG, voluntarily surrender their LPG subsidy.
If you want to give up subsidy, select
'Yes'
below. If you want subsidy, select
'No'
below:
Yes
No
Choose an option:
I have Aadhaar
I do not have Aadhaar
Aadhaar No
*
:
Verify Aadhaar
IFSC Code
:
Bank Name
:
BankName
Account Type
:
Savings
Current
Bank Account No
:
Confirm Bank Account No
:
Your Name as per Bank Account
:
5) Document Submission
Submit Photograph and required supporting documents
Upload Online
Submit to Distributor
I hereby declare that whatever has been stated in
declaration
is true to the best of my knowledge, correct and nothing has been concealed in the form.
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