Application Format For Individual Applicants

(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE / BLACK BALL POINT PEN)
For Office use D D - M M - Y Y Passport Size
Not to be filled by applicant
Photograph
Office Code Serial No Date of receipt of application
with specimen
signature on
APPLICATION FOR LPG DISTRIBUTORSHIP OF the photograph
Please write name of Oil Company of the location (BPC or IOC or HPC)
Particular of application fee `
Demand Draft Number Date D D - M M - y y
(name of the bank)
Drawn on Payable At
In favour of (Full name of the oil company)
(Enclose Application processing fee of `1000/- (one thousand only) for all applicants except SC/ST candidate.
Application processing fee for SC/ST candidates is ` 500/- (Five hundred) on enclosing SC/ST certificate.

1 Name of the Location

2 District
3 State
4 Category

Please attach copy of Eligibility Certificate of respective category from the competent authorities. Not
Applicable for locations under 'Open' category.

5 Advertised on D D - M M - Y Y Y Y in (Please write Name of Newspaper)

6 Status of applicant: Individual YES / NO if 'No' Please use the format for
non-individual applicant.
7 Applicant should enclose Affidavit as per the format given in Appendix - 1
7.1 Name
First name Middle name Surname

7.2 Father’s / S H R I
Husband’s Name Title First name Middle name Surname

7.3 Address

Pin code :
Telephone No - email:
7.4 Indian Citizen Yes No Resident of
if 'No' applicant is not eligible
7.5 Gender Revenue District
Male / Female
State
7.6 Date of Birth - - Age Years Months Days
Age as on the date of application
D D - M M - Y Y Y Y
Strike off what is not applicable.
7.7 Marital Status Single / Married / Widow / Divorcee
7.8 Name of Spouse,
If married

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 8 I. Educational Qualification
Qualification University / Institution Degree Year of Passing
i) Graduation in any other field
ii) Chartered Accountant
iii) Cost Accountant
iv) Company Secretary
v) Diploma in Engineering
Please Read Item no 9 & 10 of General Instruction before providing the information on 9 & 10 below.
9 Provide the following details of land for construction of LPG godown or constructed LPG godown (within 15 km
from municipal/town/village limits of the advertised location in the same State) owned or leased for minimum
15 years in the name of applicant / member of 'Family Unit'. In case land belongs to member of 'Family Unit',
attach notarized affidavit as per Appendix - 2.
Name(s) of the owner Relationship Date of registration of Address of the Khasra Dimensions of land * Distance
of Land / Leaseholder with applicant sale deed/gift deed / location of the land No/Survey from location
lease deed/ date of for LPG Godown No Length in Breadth in in km
mutation metre metre

* Give the dimensions of the plot that will be used for proposed godown out of the total land owned.
10 Provide the following details of land for Showroom or showroom at the advertised location (owned or leased
for minimum 15 years). In case land belongs to member of 'Family Unit', attach notarized affidavit as per
Appendix - 2
#
Name(s) of the owner of Land Relationship Date of registration of Address of the Khasra Dimensions
/showroom or leaseholders with applicant sale deed/gift deed / location of the land No /
lease deed / date of for Survey Length in
mutation showroom/showroom No
Breadth in
metre metre
.

# Give the dimensions of the plot that will be used for proposed showroom out of the total land owned.
Please read item no 11 & 12 of General Instruction before providing the information on 11 & 12 below.
11 AMOUNT IN SAVINGS BANK ACCOUNT IN SCHEDULED BANK/ POST OFFICE as on the date of
application in the name of applicant and members of 'family unit'. Attach notarized affidavit as per format
given in Appendix-2 from member(s) of 'family unit'.

S.N Name of Bank S. B. A/C No. Name of Relation Amount as on date of application.
account holder with
(s) applicant
1 ` -
2 ` -
3 `
4 `
5 `
TOTAL ` -
Total amount in words.

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 12 FIXED DEPOSIT/NSC/SHARES/MF etc., as on date of application in the name of applicant and members of
'family unit'. Attach notarized affidavit as per format given in Appendix - 2 from member(s) of 'family
unit'.

S.N Type of Reference Name(s) of Relation Initial Value (Amount) as on the date of
Investment Number with the holder with investment application
- date applicant Amount
FD/NSC/Sh
ares/MF etc
1 ` -
2 ` .
3 `
4 `
Total ` .
Total amount in words.
Have you ever been convicted or charges have been framed by Court of Law for Yes / No
13 any criminal offence involving moral turpitude and / or economic offence (other than Please strike off what is not applicable
freedom struggle)? (If yes you are not eligible to apply.)

14. DECLARATION BY THE APPLICANT

a. I am aware that eligibility for LPG distributorship will be decided based on the information
given in the application above. On verification by the Oil Company if it is found that the
information given by me is incorrect/ false/ misrepresented then my candidature will stand
cancelled and I will be declared ineligible for LPG Distributorship.

b. I also confirm that I am in possession of the supporting documents in original in respect of

the information given by me in this application and if selected, failure to present these
documents in original will result in cancellation of selection due to submission of
false/unsupported information in this application.

c. I am fully aware that if I am unable to provide duly approved LPG Godown by the Office of
Chief Controller of Explosives (PESO) and or Showroom as per the Oil Company’s
standard layout, then the allotment of distributorship made to me will be cancelled.

d. I am fully aware that I will not be appointed as LPG distributor if I am employed. I shall
have to resign from the service and produce proof of acceptance of my resignation from
my employer before issuance of Letter of Appointment.

e. I am fully aware that I will have to personally manage the operation of the LPG
Distributorship.

f. I am aware that if married, my spouse will be co-owner i.e. 50% partner of LPG
Distributorship with me and I am not permitted to enter into partnership with anyone other
than my spouse.

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g. That, if selected, I undertake that I will be depositing an interest free Security deposit as
per the policy of the Corporation

h. I confirm that I fulfill the eligibility criteria for the LPG distributorship I have applied for in
this application

Undertaking

I, _________________________________________________________daughter of /son of/

wife of Shri__________________________________ hereby confirm that the information
given above is true and correct. Any wrong information /misrepresentation/ suppression of
facts will make me ineligible for this LPG distributorship.

Place : _____________ Signature of applicant_______________________

Date :______________ Name of applicant_____________________________

List of Enclosures
1. Copy of Eligibility Certificate for the category applied.
2. Demand Draft No_______________________ dated ________________
3. Notarized Affidavit in originals per the format in Appendix -1
4. Notarized Affidavit in original as per the format in Appendix -2
5. Total number of pages of the application including attachments

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 Appendix - 1
Notarized Affidavit
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED
VALUE)

I,____________________________________ son/daughter/wife of ______________________________

Age _____ years residing at __________________________ do hereby solemnly affirm and say as under :

1 That I am an Indian Citizen and residing in India.

2 That my date of birth is d d / m m / y y y y (in words______________________________)

3 That I passed Graduation examination from recognized University / Institution in the year* y y y y
and / or
That I have passed & completed the course of Chartered Accountant in the year* y y y y
and /or
That I have passed & completed the course of Company Secretary in the year* y y y y
and / or
That I have passed & completed Cost Accountant examination in the year * y y y y
and /or
That I have passed & completed Engineering Diploma examination in the year * y y y y
4 That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried sister(s) have
dealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV
of any Oil Company.
OR
That I am married and name of my spouse is __________________. That neither I nor my spouse, unmarried
son(s)/unmarried daughter(s) have dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO
dealership or LPG distributorship or RGGLV of any Oil Company:
OR
That I am widow /widower . That neither I nor my unmarried son(s)/unmarried daughter(s) have dealership/ distributorship
or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company:
OR
That I am divorcee . That neither I, nor unmarried son(s)/unmarried daughter(s) (whose custody is given to me) have
dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV
of any Oil Company:
5 That I am of sound mental health.

6 That I have never been convicted nor charges have ever been framed against me by any Court of Law for any criminal
offences involving moral turpitude and/or economic offences (other than freedom struggle).
7 That I hereby confirm that I was never a signatory to dealership/distributorship agreement of any Oil Company, which was
terminated for proven malpractices and / or for violations of provisions of the Marketing Discipline Guidelines.
8 That if any information/declaration given by me in my application or in any document submitted by me in support of
application for the award of the LPG Distributorship or in this affidavit shall be found to be untrue or incorrect or false, the
Indian Oil Corporation*/ Bharat Petroleum Corporation* /Hindustan Petroleum Corporation* would be within its rights to
withdraw the letter of intent / terminate the distributorship (if already appointed) and that I would have no claim,
whatsoever, against the Corporation for such withdrawal / termination.
* Strike off whatever is not applicable.
I hereby verify that what has been stated above is true and correct to the best of my knowledge and nothing
material has been concealed there from.

Solemnly affirmed and declared before me. This ___________day of ________________

Signature and Seal of Signature of person making affidavit

Magistrate/Judge/Notary public (Name in block letters)

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 Appendix – 2

Notarized Affidavit
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
(To be given by the family member as defined in eligibility criteria other than
applicant)

I _____________________________________ Son/wife
of________________________________ age______years resident of
_____________________do hereby solemnly affirm and say as under:-

1. That I am unmarried and my father*/mother*/unmarried brother* / unmarried sister*

(Mr/Ms)__________________________________(name) has applied for LPG distributorship
of IOC*/BPC*/HPC* at _______________(location) under '__________' category against the
advertisement made in __________________news paper dated__________________
OR

That I am married and my unmarried son*/ unmarried daughter*/wife*/husband*

(Mr/Ms)__________________________________(name) has applied for LPG distributorship
of IOC*/BPC*/HPC* at _______________(location) under '__________' category against the
advertisement made in __________________news paper dated__________________

* Strike off whichever is not applicable.

2. That in case he/she is selected for LPG distributorship I have no objection for construction of
godown / showroom on the land specified in item no 9 & 10 in my name.

3. That in case he/she is selected for LPG distributorship I will provide financial assistance to the
extent of amount which is mentioned at Item no.11 & 12 under my name in the application
submitted by (Shri/Smt/Kumari)___________________________for LPG distributorship of
IOC*/BPC*/HPC* at ____________________________

I hereby verify that what has been stated above is true and correct to the best of my knowledge,
and nothing has been concealed there from.

Solemnly affirmed and declared before me

This_________________________ day of ______________________________

Signature and Seal of Signature

Magistrate/Judge/Notary Public Name of Deponent and Relationship
with applicant

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 Appendix – 3a

Standard Format for SC/ST Category Certificate

Note: A candidate who claims to belong to one of the Scheduled Castes / Scheduled Tribes should
submit in support of his / her claim, a certificate in original, with a copy thereof in the form given
below, issued at any time by a competent authority # notified by the Government of India, of the
district in which his parents (or surviving parents) ordinarily reside who has been designated by the
State Government concerned as competent to issue such a certificate. If both his parents are
dead, the officer signing the certificate should be of the District in which the candidate himself
ordinarily resides otherwise than for the purpose of his own education. In case of any doubt about
the genuineness of the certificate, the same may be got verified through the concerned District
Magistrate / Deputy Commissioner.

The form of the certificate to be produced by Scheduled Castes / Scheduled Tribes

candidates.

This is to certify that Shri / Smt. / Kum* ______________ son / daughter* of ________________ of
village / town * ______________ in District / Division* _______ of the State / Union / Territory* of
___________ belongs to the ________Caste / Tribes and his / her religion is ___________ which
is recognised as a Scheduled Castes / Scheduled Tribes under the Scheduled Castes / Scheduled
Tribes lists (modification) order 1956* read with the Bombay Re-organisation Act, 1960 and the
Punjab Reorganisation Act 1956*.

The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956*

The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1956*
The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962*
The Constitution (Pondicherry) Scheduled Castes Order, 1964*
The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967*
The Constitution (Nagaland) Scheduled Tribes Order, 1970*

Place : ____________ Signature : ______________

Date : ____________ Designation : ______________
(with seal of office)
State / Union Territory*
* Please delete the words, which are not applicable
Note : The terms “Ordinarily reside(s)” used here will have the same meaning as in Section-20 of
the Representation of the People Act, 1950.

# Officers competent to issue Caste / Tribe certificates.

i. District Magistrate / Additional District Magistrate / Collector / Deputy Commissioner / Additional
Deputy Commissioner / Deputy Collector, 1st Class Stipendiary Magistrate / City Magistrate ***
Sub-Divisional Magistrate / Taluka Magistrate / Executive Magistrate / Extra Assistant
Commissioner.
*** (Not below the rank of 1st Class Stipendiary Magistrate)
ii. Chief Presidency Magistrate / Additional Chief Presidency Magistrate, Presidency Magistrate
iii. Revenue Officers not below the rank of Tehsildar.
iv. Sub-divisional officer of the area where the candidate and / or his family normally resides.
v. Administrative / Secretary to Administrator / Development Officer (Lakshadweep).

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 Appendix – 3b

Standard Format for PH Category Certificate

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE

Certificate No.
Date

CERTIFICATE FOR THE PERSONS WITH DISABILITIES

This is to certify that Shri/Smt./Kum._____________ wife/daughter/son of Shri

_______________________ Age ______________old male/female, Registration No.
______________________________ is a case of physically disabled/visual
disabled/speech & hearing disabled and has ____________ % (____________________)
permanent (physical impairment/visual impairment/speech & hearing impairment) in
relation to his/her ____________________________________________________

Note: -

1. This condition is progressive/non-progressive/likely to improve/not likely to improve. *

2. Re-assessment is not recommended/is recommended after a period of
_______months/years.

*Strike out which is not applicable.

Sd/- Sd/- Sd/-

(DOCTOR) (DOCTOR) (DOCTOR)
Seal Seal Seal

Signature/Thumb impression of the patient

Countersigned by the
Medical Superintendent/CMO/Head of
Hospital (with seal)

Recent Attested Photograph

Showing the disability affixed here

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 Appendix – 3c

Standard Format for Paramilitary/Police/Government Personnel

Category

(Certificate is to be given by Head of the Office or an Officer not below the rank of Under
Secretary to the Government on Official Letter-Head of the Organization / Government Office
issuing the Certificate)

NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE

Reference No
Date
Eligibility Certificate for Paramilitary/Police/Government Personnel Category

1. @ This is to certify that Shri/Smt./Kum. ________ who was working in this office as
________ had passed away on (date) _______ at (Place)___________. Shri/Smt./Kum.
________ has been awarded ( name of gallantry award)________in recognition of the
supreme sacrifice made while__________________, Shri/Smt./Kum. ( name of applicant)
_________________ (relationship ___________ ) was dependent on Shri/Smt./Kum.
Shri/Smt./Kum. ____________ as per our records.

OR
2. @This is to certify that Shri/Smt./Kum. ___________________________________who
was working in this office as ______ had passed away on (date) ________________ while
in action at (Place)______________ Shri/Smt./Kum. ( name of applicant)
_________________ ( relationship ___________ ) was dependent on Shri/Smt./Kum.
____________ as per our records.
OR

3. @This is to certify that Shri/Smt./Kum. (name of applicant)__________________________

was working in our organization ________ and has been disabled on ( date)
_________while performing duties at (place)________.
OR

4. @This is to certify that Shri/Smt./Kum. ___________________________________who

was working in this office as ______ had passed away on (date) ________________ while
on duty at (Place)______________ Shri/Smt./Kum.( name of applicant)
_________________ ( relationship ___________ ) was dependent on Shri/Smt./Kum.
____________ as per our records.
OR

5. @This is to certify that Shri/Smt./Kum. _________ was working in our organization

________ and has been disabled in peace on ( date) ----------- due to attributable causes.

@ Delete if not applicable.

Attested Signatures of applicant

Place : ____________ Signature :

Date : ____________ Name :
Designation:
Office Seal:

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 General Instructions to the candidates applying for LPG Distributorship
Item Instructions Supporting Documents to be
No provided by applicant at the
time of verification.
1 Write the name of the location for which application is made as per
advertisement.
2 Write the name of the district of the location for which application is
made as per advertisement.
3 Write the name of the State of the location for which application is
made as per advertisement.
4 Write the name of the category of the location as per the Eligibility Certificate issued by the
advertisement competent authority in format 3a
or 3b or 3c as applicable.
5 Write the date and name of the newspaper in which advertisement has appeared for the location mentioned
in item 1.
6 Tick the status of Applicant: whether application is individual Yes or No. If No use the application format of
Non-Individual Applicant
th
7 Personal Details are to be filled and Notarized Affidavit as per Proof of Date of Birth 10
format given in Appendix -1 to be submitted Standard Board Certificate / Birth
Certificate/Passport.
8 Education: - Information in chronological order Original certificate for each
qualification
9 Details of the plot of Land for godown or ready made godown as Documents pertaining to land /
on the Date of Application which meets the following requirement:- Godown in the name of applicant
or member of 'family unit'
the plot of land should be of adequate size (within 15 km from Registered Sale Deed/ Registered
municipal/town/village limits of the location offered in the same Gift Deed / Registered Lease
State) for construction of godown for storage of minimum 8000 Kg Deed (15yrs minimum) / Mutation
of LPG in cylinders or ready LPG cylinder storage godown. As per and government record etc.
Gas Cylinder Rules 2004, the floor area of the storage shed for
storing 8000 kg LPG in cylinders should be 80 sq metres. The The Date of the documents have
length of the storage shed should not be more than 1.5 times of to be on or before the date of
width of storage shed. There should be clear minimum safety application.
distance of 7 metres between storage shed and the boundary wall/
fencing. In case land is in the name of
member of 'family unit', consent
A plot of land with minimum dimension of 26.15 metres by 27 from the family member in form of
metres is adequate. It should be freely accessible through all Notarized Affidavit (Appendix 2)
weather motorable approach road (public road or private road is required to be attached with the
connecting to the public road). It should also be plain, in one application.
contiguous plot, free from live overhead power transmission
'Family Unit' is defined below in
Important Note.

10 Details of the Land for showroom as on the Date of Application Documents pertaining to land /
which meets the following requirements:- showroom in the name of
applicant or member of 'family
Own a suitable shop of minimum size 3 metres by 4.5 metre in unit'. Same as mentioned in the
dimension or a plot of land for construction of shop of minimum item 9 above.
size 3 metres by 4.5 metre at the advertised location or locality as
specified in the advertisement. It should be easily accessible to
general public through a suitable approach road.

10
Item Instructions Supporting Documents to be
No provided by applicant at the
time of verification.
11 Amount in the Savings Bank Account in Scheduled Bank / Post Savings Bank Accounts
Office in the name of self & the member(s) of the "Family Unit" as Statement/Pass Book from which
on the date of application only will be considered. Amount amount as on the date of
maintained in the joint account with member(s) outside the “Family application can be verified.
Unit" should not be mentioned. Attach Notarized Affidavit as per
format given in Appendix -2
12 Investment in Bonds/NSCs/value as on Date of Application in the Original investment documents
name of self and member of the "Family unit". based on which amounts has
been mentioned in the application
Fixed Deposit/Term Deposit /PPF in Scheduled Bank/ Post office/
listed Companies/Government Organization / PSU - amount as on
the date of application.

Amount maintained in the joint account with member(s) outside the

“Family Unit" should not be mentioned and will not be considered.
Attach Notarized Affidavit as per format given in Appendix - 2
Investments in Mutual Funds/listed company shares/ULIP based Value on the date of application
on the NAV on the date of application. as certified by the Government
Approved Valuer or the concerned
financial institution/ certified by
Chartered Accountant.
Amount of money which applicant can get on surrender of Certificate from the Insurance
Insurance policy. Company
13 Conviction or charges have been framed by Court of Law for any Notarized Affidavit as per format
criminal offence involving moral turpitude and / or economic given in Appendix -1 to be
offence (other than freedom struggle). submitted
Important Note :
1) ‘Family Unit’ of a married applicant, shall consist of self, applicant's spouse and unmarried
son(s)/daughter(s) and ‘Family Unit’ of a unmarried Applicant, shall consist of self, applicant's
parents and applicant's unmarried brother(s) / sister(s) for the purpose of this entire application.
2) Applicant should provide only that information in the application against various items, for which
applicant is in possession of supporting documents in original as on the date of submission of
application. Failure to present these documents in original at the time of verification can result in
cancellation of selection.
3) Incase applicant requires extra space for providing details on any point, the details can be provided
by adding extra rows or by adding extra sheets. However, details should be given in the same format
as mentioned in that particular point.

Check list for Applicants

S.No Document / Activity to be checked Check Box
1 DD attached - verify amount, drawn in favour of concerned Oil Company and payable at
2 Photograph pasted and signature across photograph
3 Copy of eligibility certificate for the category attached as applicable
4 Notarized Affidavit in original as per format given in Appendix - 1 attached.
5 Notarized Affidavit in original as per Appendix -2 as applicable
6 Undertaking in at the end of application duly signed with name, date and place
7 All pages of application are numbered and signed
8 Total Number of pages
9 The Application is complete in all respect

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