1. HINDUSTAN PETROLEUM CORPARATION
Scopr Minar 6TH ,North Tower, Laxmi Nagar, New Delhi
( On Rs,20 /- NON JUDISCAL STAMP PAPER )
Shri/Smt/Kum ________________________________________________
Husband/Wife/Son/Daughter of __________________________ aged about
___/___/____ years, resident of _________________ _________________
______________________________ (address ) do solemnly affirm and state as follows::
1. I do not possess a ration card and am producing Electricity bill / House allotment
letter or and other as proof of my resident
OR
2. I am holder of ration card No_______________________ and am producing the
same proof of my residence.
3. I am not an existing LPG /PNG connection from any oil company / OR and will
not possess one, in future, in the same premises / Hose hold.
4. On the basis of the above I will issued the following equipment. Ownership of
which will be with Hindustan Petroleum Corporation LTD through its diributor
M/s KAMAKHYA ENTERPRISES as and when returnable to Hindustan
Petroleum Corporation / M/s KAMAKHYA ENTERPRISES.
(HP Gas Distributes)
1. Cylinder-One / Two ( as applicable )
2. regulator –One
5. I have received the HP Gas instruction Card and agree to follow such instructions
given by you from time to time.
DEPONENT
Verification
Solemnly affirm by the within Name ____________________________ at
________________________ on this ___________________ day
of___________________ that paras__________________________ to
___________________ are true my to my Knowledge.
DEPONENT
Signature of customer
Cell No/Phone No.
