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g yo ation 8 atl os Pradhan Mantri Ujjwala Yojna. UIIWALA KYC Application " fforeren20 00 oe re 1b fia ina ik wt LOCK LETTERS. ir an fixe 21 ae of Spank me 7 Pr[eeserorn| | "ayers 1 [First Name pM 7 ple name 7 ne a 1 Poot res POA eatery Code™ PP a 7 we Ft ee ro 7 fete Compl / Bg tank = anne = fy own rca «as anv as 7 peck sub rot o = a ©) Petals of Household members aged above 18 ys (onsite Ietationship with ar fre fear ame Fst Name pinta ea @) PARTIULARS OF MY AADHAAR CARD (oma yet phere) 1 [Name in Aadhaar Card 2 [padhaar Number “PARTICULARS OF MY BANK ACCOUNT (ach coy of poi ends code pried ot) [name in Bank Account laank Name laranch Name lrsccode 5 [bank Account Number Flan card dete ance otra state of ssue [ation cara Number Details Of Pradhan Mantri Ujwala Yojna * ust of POR dens doa (0) “90001 Under Pradhan Mant Ujwala Vojna free LPG connections are provided by 01 Marketing Companies (OMCs) tothe women belonging to the Below Poverty Line (8PL) household 2) The scheme provides cosh assistance to cover the cost of Security Deposit of Cylider, Pressure regulator, ‘of DGCC, Suraksha hose and installation & administrative charges |) Information submitted inthis KYC form wil be verified against authorised ist of 8PL population available ‘oMcs, On sucessful verfcaton & confirmation of non enistnce of POS LPG connection at your premises, LPG nection may be released to you subject to applicable terms & conditions. sleghonefeleccty Mater bl: POAOS if ecarton atest by Santadfeer- OAD? Flt aicenerfoosesin eter POND sheds card Stree POM? g yo ation 8 atl os [Fawinment Selection (rex he appropracebow/ bones) 1 ype of 16 eynder desired (et he eed espmer) 4.2 ke olinder keener 2 [Po youneed LPG stove from distributor yer orm) (es 0 Jocor ire distributor, p davpherite ct. fae. yrs, resident of lesa to tke domes 16 connection In my name and ana under 1} there by Conf ht, The Information urbe a th form correc and nothing materia has hen concealed therefrom andl undestand that, foe Information any wll ‘tects punishment ander indian Perel Cos 1) shallot hold 10¢/HP

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