KnowYourCustomer(KYC)Form(WaitlistID:16346363)1)PersonalDetailsNameOfConsumer*Salutation(Mr./Ms./Mrs/Miss)*: MRSFirstName*: VIMALAMiddleName: PARASLastName*: PALIYA

GasConsumerNumber: (Onlyforexistingcustomers)DateOfBirth*:12081979(DDMMYYYY)

NameofDistributorship: VIMALGASSERVICE(110906)

Father'sName*: SpouseName:PARASPALIYAMother'sName: RADHADEVIMOURYA2)AddressforLPGconnection/ContactInformation

ProofOfAddress(POA)POACategory: POA03LeaseAgreement POADetail:971552242805House/Flat#,Name: ROOMNO28 FloorNo:1STFLOOR

HousingComplex/Building: ADARSHNAGARNO2 LandMark:OPPHANUMANMANDIRStreet/RoadName: SHELLCOLONYCity/Town/Village: MUMBAI PINCode:400071District: MUMBAISUBURBAN State:MaharashtraMobileNo: 9619093740 Landline:EmailID: anilmourya5@gmail.com3)OtherRelevantDetails

ProofOfIdentity(POI)POICategory: POI01Aadhaar(UID) CardNumber:971552242805

RationCardDetailsifAvailableStateOfIssue: Maharashtra RationCardNumber:1062816

Declaration:Iherebydeclarethattheinformationprovidedbymeaboveistrueandcorrecttothebestofmyknowledgeandbelief.Ialsoconfirmthatintheeventofanyinformationprovidedbymeisfoundincorrect/isincompleteandalsointheeventofanyviolationofGovernmentRegulationrelatedtothesupplyanddistributionofLPG,BPCwillbewithinitsrighttodiscontinuesupplyofLPGcylinderstome,forfeitofsecuritydepositandcanlevypenalchargesasperthepolicyandguidelinesandmayinitiatelegalactionapplicableunderprovisions.

IalsoconfirmthatIdonothaveanyobjectioninreceivingSMSfromBPCLonthemobilenumbergiveninthisform.

Name&Signature: Date:

TobefilledbyDealer/DistributorIconfirmhavingverifiedthephotocopiesofdocumentsaboveagainsttheiroriginals.

ConsumerNumber(Ifallotted):

SignatureofDistributorVIMALGASSERVICE Date:

TearOffI/We,hereby,confirmreceiptofdulyfilledinKYCformalongwithrelevantPOI,POAdocumentsformNameMRSVIMALAPARASPALIYAConsumerno(ifapplicable)on____________________(date)

SignatureandSealofDistributor