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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-
AMRITSAR
BARNALA
BATHINDA
FARIDKOT
FATEHGARH SAHIB
FAZILKA
FIROZPUR
GURDASPUR
HOSHIARPUR
JALANDHAR
KAPURTHALA
LUDHIANA
Malerkotla
MANSA
MOGA
PATHANKOT
PATIALA
ROOPNAGAR
S.A.S. NAGAR
S.B.S NAGAR
SANGRUR
SHRI MUKTSAR SAHIB
TARNTARAN
Distributor:
-Select-
BABA FATEH SINGH BHARATGAS
COMMANDO GAS SERVICE
DASHMESH BHARATGAS
DEEP BHARATGAS
DERABASSI BHARAT GAS
DIVINE BHARAT GAS
GO GREEN BHARAT GAS
HEMKUNTH SAHIB GRAMIN LPG VITRAK
KAPOOR BHARATGAS
KOHINOOR BHARATGAS
MAL GRAMIN LPG VITRAK
NANAK BHARATGAS
NANWA BHARATGAS
OM BHARATGAS
PARAMOUNT BHARATGAS
RAVINDER ENTERPRISES
SHAHEED SUBEDAR BALBIR SINGH GAS
SHIV BHARATGAS
SUPERFLAME BHARATGAS
UNIVERSAL BHARATGAS
VINEET BHARATGAS
VIRDI GAS SERVICE
Pin Code
*
:
-Select-
140103
140109
140110
140112
140201
140301
140307
140413
140501
140506
140507
140603
140604
140901
160003
160103
160104
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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