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    Know Your Customer (KYC) Form: 1) Personal Details (MR./MRS./MS)

    Uploaded by

    Jagadish Data
    This document is a "Know Your Customer" (KYC) form used to collect personal and identity information from customers applying for an LPG gas connection. The 3-sentence summary is: The KYC form collects the applicant's personal details including name, date of birth, gas consumer number if applicable, and close relative details. It also requires the applicant to provide proof of address and identity documentation, and includes fields for entering details of these documents like category codes. The applicant must declare that the information provided is true and correct, and agrees to terms regarding use of the information and consequences of providing incorrect details.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Know Your Customer (KYC) Form: 1) Personal Details (MR./MRS./MS)

    Uploaded by

    Jagadish Data
    97 views2 pages
    This document is a "Know Your Customer" (KYC) form used to collect personal and identity information from customers applying for an LPG gas connection. The 3-sentence summary is: The KYC form collects the applicant's personal details including name, date of birth, gas consumer number if applicable, and close relative details. It also requires the applicant to provide proof of address and identity documentation, and includes fields for entering details of these documents like category codes. The applicant must declare that the information provided is true and correct, and agrees to terms regarding use of the information and consequences of providing incorrect details.

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    KYCForm

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    This document is a "Know Your Customer" (KYC) form used to collect personal and identity information from customers applying for an LPG gas connection. The 3-sentence summary is: The KYC form collects the applicant's personal details including name, date of birth, gas consumer number if applicable, and close relative details. It also requires the applicant to provide proof of address and identity documentation, and includes fields for entering details of these documents like category codes. The applicant must declare that the information provided is true and correct, and agrees to terms regarding use of the information and consequences of providing incorrect details.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    97 views2 pages

    Know Your Customer (KYC) Form: 1) Personal Details (MR./MRS./MS)

    Uploaded by

    Jagadish Data
    This document is a "Know Your Customer" (KYC) form used to collect personal and identity information from customers applying for an LPG gas connection. The 3-sentence summary is: The KYC form collects the applicant's personal details including name, date of birth, gas consumer number if applicable, and close relative details. It also requires the applicant to provide proof of address and identity documentation, and includes fields for entering details of these documents like category codes. The applicant must declare that the information provided is true and correct, and agrees to terms regarding use of the information and consequences of providing incorrect details.

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    © All Rights Reserved
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    Form KYC Version 3 - 2014-BPC

    Know Your Customer(KYC) Form


    (To be filled in black ink with BLOCK LETTERS. Fields marked with * are mandatory)
    ( For Instructions to fill form please see overleaf)
    1) Personal Details Paste your photo
    here
    (Mr./Mrs./Ms) *
    First Name*
    Middle Name
    Last name*

    b) Gas Consumer Number* c) Date of Birth*


    D D M M Y Y YY
    d) Close Relative Father’s /Spouse Name*
    Mother’s name*

    2) Address for LPG connection / Contact Information


    Proof of Address ( POA) category Code*P O A
    House/ Flat #, Name* Floor No*
    Housing Complex/Building Land Mark
    Street/Road Name
    City/Town/Village * Pin Code*
    District * State*
    Phone #* : Mobile No Landline #
    Email id
    3) Other Relevant Details
    a) Proof of Identity (POI)
    POI Category Code* P O I
    Card Number*
    b) Ration Card Details if Available
    State Of Issue
    Ration Card Number
    Declaration: I hereby declare that the information provided by me above is true and correct to the best of my knowledge and
    belief. I also confirm that in the event of any information provided by me is found incorrect / is incomplete and also in the event
    of any violation of Government Regulation related to the supply and distribution of LPG, IOC/BPC/HPC will be within its right to
    discontinue supply of LPG cylinders to me, forfeit of security deposit and levy of penal charges as per the policy and guidelines
    and may initiate legal action applicable under provisions.

    Name & Signature of Applicant * Date:-


    _______________________________________________________________________________________________________
    To be filled by Distributor
    I confirm having verified the photocopies of documents above against their originals.

    Consumer Number (If allotted):

    Signature of Distributor Date:


    Name of Distributorship with SAP Code
    -----------------------------------------------------------------------Tear Off -----------------------------------------------------------------------------

    Acknowledgement

    I/We, hereby, confirm receipt of duly filled in KYC form along with copy relevant POI, POA documents from

    Name _______________________________Consumer no (if applicable)_________________ on______________

    Signature and Seal of Distributor


    Instructions for Filling KYC Form
    Fields marked with * are mandatory and must be filled in by person submitting KYC
    1 a) Name Name to be entered as given in Photo ID Proof
    1 b) Gas Consumer Mandatory for consumers already using LPG from IOC/BPC/HPC
    Number
    1 c) Date of Birth Mandatory to provide Date of Birth
    1 d) Details of Close Father or Spouse and Mother’s name is mandatory. Please strike off whichever
    Relative is not applicable.
    2 Proof Of Address At least copy of one of the documents listed below should be attached and
    ( POA) category mentioned in the form. The Address to be entered against the
    relevant fields exactly as it appears in the POA. Person submitting KYC is
    required to produce the original of document for verification by the distributor.

    List of documents Category Code


    Aadhaar (UID) POA01
    Driving License POA02
    Lease agreement POA03
    Voter ID POA04
    Telephone/Electricity /Water bill POA05
    Passport POA06
    Self-declaration attested by a Gazetted officer. POA07
    Ration Card POA08
    Flat allotment/possession letter POA09
    House registration document POA10
    LIC Policy POA11
    Bank/Credit Card Statement POA12

    3 a) Proof of Identity At least copy of one of the documents listed below should be attached and
    (POI) category mentioned in the form. Consumer is required to produce the original
    of the document for verification by the distributor.

    List of documents Category Code


    Aadhaar Number (UID) POI01
    Passport Number POI02
    PAN Card Number POI03
    Voter ID Card POI04
    ID card Issued By Central/State POI05
    Driving License POI06

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