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CONSUMER INFORMATION SHEET (Wait list ID: 9348024) Name of Distributorship: Name Of Consumer* Salutation (Mr./Ms./Mrs/Miss)*: First Name*: Mi""le Name: #ast Name*: Consumer Number: Date Of -irth*: Father5s Name*: Mother5s Name: Name Of Spouse:

MRS SAND !A $%&'A (Name to be entere" as per &hoto (D &roof) (Onl) for e*istin+ ,ustomers) ./01/0.234 DD0MM0!!!! -R(6 7(S OR8 $%&'A 7AM#8S $%&'A RA6A' 6A(N

A""ress* (A""ress to be 9ritten as +i:en in &roof of A""ress) ouse No*: ;/.<. ouse Name/Flat Floor No*: S8COND F#OOR ousin+ Comple*/-uil"in+ No*: =(- A= 7 AND Street/Roa" Name*: $OM'( NA$AR Area/#an" Mar>: ON8!MAN C O?7 Cit)/'o9n/=illa+e*: #%C7NO? Distri,t*: #%C7NO? %''AR &RAD8S State*: %ttar &ra"esh &(N Co"e*: <</.14 'elephone Number: Mobile Number: 3;1111<1@@ 8mail (D: "r.san"h)a+uptaAli:e.,om * Man"ator) Fiel"s
At least one of the follo9in+ "o,uments of &roof of A""ress is man"ator). 7in"l) ti,> the "o,ument pro:i"e" for &roof of A""ress . Aa"haar (%(D) letter . #ease a+reement / rent re,eipt . 'elephone/8le,tri,it) or an) other utilit) bill . Self0"e,laration atteste" b) $aBette" offi,er . Flat allotment/possession letter . #(C &oli,) . Dri:in+ #i,ense . =oter (D . &assport . Ration Car" . ouse re+istration "o,ument At least one of the follo9in+ "o,uments of &roof of ("entit) is man"ator). 7in"l) ti,> the "o,ument pro:i"e" for &roof of ("entit) . &AN Car" . &assport . =oter (D . Aa"haar (%(D) letter . Dri:in+ #i,ense . Central/State $o:ernment (ssue" (D Car"s . 0 . 0 . 0 . 0 . 0

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CONSUMER INFORMATION SHEET (Page 2) Do you have Pan Number: Yes If Yes, Please enter PAN Number: AXSP !""#$ Do you have a Pass%ort: No If Yes, Please enter Pass%ort Number: Do you have a Drivin& 'icense: No If Yes, Please enter Drivin& 'icense No: Do you have a (ation $ard : No If Yes, Please enter (ation $ard No: Do you have )IDAI Aadhaar No: No If Yes, Please enter your Aadhaar No: Do you have Voter ID *+PI$,+lection Photo ID $ard-: Yes If Yes, Please enter your Voter ID No: 'PY./0.1!1 Do you have Id *Issued 2y $entral State overnment-: No If Yes, Please enter your ID No: 3ther Address Proof: Self,declaration attested by 3%tional Details 2an7 Name: 2ranch: Address: I5S$ $ode: Account Number: Declaration: I declare that the information %rovided by me on the above form is true and correct to the best of my 7no8led&e and belief9 I also confirm that in the event of any information %rovided by me is not true and incom%lete and also in the event of any violation of overnment (e&ulation related to the su%%ly and distribution of 'P , 2P$' 8ill be 8ell 8ithin its ri&ht to ta7e necessary action includin& discontinuation of su%%ly of 'P cylinders, can forfeit the security de%osit and can levy %enal char&es as %er the %olicy and &uidelines9 I am 8illin&:not 8illin& to avail the Subsidy on 'P cylinders therefore I have %rovided:not %rovided my 2an7 account details on the above re;uest form9 I also confirm that I do not have any ob<ection in receivin& S=S from 2P$' on the mobile number &iven in this form9 Signature o Cu!to"er#: Signature o Di!tri$utor#: Date: Date: Physically Verified by Distributor? Yes No Yes No Yes No Yes No Yes No

Yes No Yes No a4etted officer *S+'5 D+$'A(A6I3N-

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%Tear O %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% I:>e, hereby, confirm recei%t of duly filled in ?Y$ form alon& 8ith relevant documents of Proof of Identity and Proof of Address has been received from ,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,,, on,,,,,,,,,,,,,,,, *dateSignature an& Seal o Di!tri$utor

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