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*:
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*: POA Detail*:
House / Flat #, Name*: Floor No*: Housing Complex/Building*:
Street/Road Name*: Land Mark*: City/Town/Village*:
State*: District*: Distributor:
Pin Code*:
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*: Card Number*:  
 
Ration Card Details if Available:
State Of Issue for Ration Card: 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:
 
 
Choose an option:
IFSC Code:
 
Bank Name:  
Account Type:  
Bank Account No:
Confirm Bank Account No:
 
Your Name as per Bank Account:
 
5) Document Submission
 
  Submit Photograph and required supporting documents
 


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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