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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-
AGRA
ALIGARH
ALLAHABAD
ALLAHABAD LOCAL
AMBEDKAR NAGAR
AMETHI
AMROHA
AURAIYA
AZAMGARH
BAGHPAT
BAHRAICH
BALLIA
BALRAMPUR
BANDA
BARA BANKI
BAREILLY
BAREILLY MG
BASTI
BIJNOR
BUDAUN
BULANDSHAHR
CHANDAULI
CHITRUKUT
DEORIA
ETAH
ETAWAH
FAIZABAD
FARRUKHABAD
FATEHPUR-EAST
FEROZABAD
GAUTAM BUDH NAGAR
GAZIPUR
GHAZIABAD
GONDA
GORAKHPUR
HAMIRPUR
HAPUR
HARDOI
HATHRAS
JALAUN
JAUNPUR
JHANSI
KANNUJ
KANPUR DEHAT
KANPUR NAGAR
KASHI RAM NAGAR
KAUSHAMBI
KUSHINAGAR
LAKHIMPUR
LALITPUR
LUCKNOW
MAHARAJGANJ
MAHOBA
MAINPURI
MATHURA
MAU
MEERUT
MIRZAPUR
MORADABAD
MUZAFFARNAGAR
PILBHIT
PRATAPGARH
RAE-BAREILLY
RAMPUR
SAHARANPUR
SAMBHAL
SANT KABIR NAGAR
SANT RAVI DAS NAGAR
SHAHJAHANPUR
SHAMLI
SHRAVASTI
SIDHARATH NAGAR
SITAPUR
SONBHADRA
SULTANPUR
UNNAO
VARANASI
Distributor:
-Select-
A.V. BHARATGAS
BADAUN GAS AGENCY
BANVARI LAL BHARAT GAS SERVICE
DAKSH BHARATGAS SERVICE
JAI MA KAKORADEVI BHARATGAS SERVICE
KISAN BHARATGAS SERVICE
MA DURGA BHARATGAS SERVICE
MAHAVIDHYA BHARATGAS SERVICE
MAHIMA BHARATGAS SERVICE
RADHA GOVIND BHARATGAS
RAMAYA BHARATGAS SERVICE
SHASHI N.D.BHARAT GAS
SHRI GURU KRIPA BHARATGAS
SHRI SHIV BALAJI BHARATGAS
SHRI VANKHANDI MAHADEV BHARATGAS
SHUBH KRISHNA BHARATGAS
SINGH ENTERPRISES
Pin Code
*
:
-Select-
242021
243601
243630
243631
243632
243633
243634
243635
243636
243637
243638
243639
243641
243720
243723
243724
243725
243726
243727
243751
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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