‘PAYMENT IN CASH IS NOT ACCEPTED INDRAPRASTHA GAS LIMITED J (Joint Venture of GAIL. (India) Lid, BPCL & Government of NCT of Dethi) " [GL Bhawan, Pot No.4 Community Centre, Sector, RK. Puram, New Delhi110022 APPLICATION FORM FOR REGISTRATION & SUPPLY OF DOMESTIC PIPED NATURAL GAS CONNECTION (To be filled in Block/Capital Letters Only) Dates} We wish to register for domestic Piped Natural Gas connection as per details mentioned below :- NAME: Mr/Ms/Mrs, Father'sHlusband’s Name ‘Address : House No. Stret/ Area Society state Pincode Mobile No Contset No Asdhasr No, maa peat Onn pase) Ome] Roncat] Ni Engin a ahora re or atria it NOC* oe isu by the owner oh pop ‘Rte let agement wh the fl veo he pri, Proof of Residence : (Anyone tobe Enclosed) — C] Electicty Bil Latest) [C] Water Bill(Lates) [Sale Deed (1 House tax Receipt Latest) [Z] Aotment Letter (Fom Govt. Authority or Land Owning Ageney) [_] Mutation Cetiate ‘Customer LPG Connection Detai a Indane Gas (Indisn 01) Bharat Gas (Bharat Petroleum) Do you have ax LPG connection: []¥es[—]No ies plese ‘ Oo ‘ » [EHP cas indus Petotsum []Other Name of LPG Distributor: Consumer No. ‘Unique LPG ID (17 Digits) PAYMENT DETAILS : Pay Order/DD/Cheque No. Date Drawn on favoring “INDRAPRASTHA GAS LIMITED” Amount as per the plan/Scheme opted. [Note : Non-Refundable adional charges applicable tobe paid on completion ofthe isallation as per Clause No.2 of Customers’ Rights & Oiigatons DECLARATION: Thereby declare that the detals furnished by meare true and correct tothe best of my knowledge and belief. Thereby further declare that [have read and understood the Terms and Conditions (including undertaking w.rt. LPG Connection) mentioned overleaf and I accept the sameinits entirety. lacknowledge the receipt ofthe copy of the Terms and Conditions vide Customer Copy. Plan/Seheme Opted Please eke Sb amount Payable upfront [__] EMI[__] Fixed Daily Charges (FDC)|__] “= Fay SD oun OG pt and € SO conti arm 28.08.21 31122087 ‘Seat fe Aptian) Fae EMI edn caren (on reds) of € 25) have been waved ff (rom 22.08 2021 31.12.2021) * NO OBJECTION CERTIFICATE (NOC to be Filled by the lawful Owner) (Applicable only if the premise is not owned) This iso ery hat, Me/Ms Ms. am the lawl owner ofthe above-mentioned property. Ihave no objection, ifthe person applying for PNG domestic conneetion as mentioned above, avails connection in ise name from IGL Permanent Address of Owner Contat No. / Maile No. Proof of Ownership (as enclosed) SignatureTERMS AND CONDITIONS FOR SUPPLY OF PIPED NATURAL GAS TO DOMESTIC CONSUMERS. ‘The AGREED TERMS AND CONDITIONS BETWEEN THE Inérapratha Gas Lt. (hereinafter refered to as “Supplier” and the applicant (hereinafter ‘referred to as "Customet") fr the supply of Piped Natural Gas (PNG) are stated below: ae maseeae mae {nan ese rr Se eceeeertatetetmetianetoeemrinnte UNDERTAKING W.RLT, LPG CONNECTION (AS PER GOVERNMENT DIRECTIVES): ‘The Customer hereby undertakes to Surrender the Subsidized LPG connection ‘OR’ Keep the Subsldled LPG connection in Safe Custody "OR! Convert the Subsidized LPG conneston to Non-Subsiized one, ifany, obtained from Government Oil Company) within sixty days of obtaining PNG connection from the Sele filing which the Seller shall have absolute igh to disconnect the PNG connection provided othe Customer.. INDRAPRASTHA GAS LIMITED ans entire of GAL ds) Ld BPCL & Govern of NC of Deh ‘TERMS AND CONDITIONS FOR SUPPLY OF PIPED NATURAL GAS TO DOMESTIC CONSUMERS "TueACRIED THMS AND CONDITIONS BET TH drt Ca ecto i apa ed “Comma ene “Tae Castomer here ndertakesta Surrender the Subd LPG connection ‘OR’ Ke the Subir LPG connection in Safe Canady "OR Convert the Sabie Re ByPODDICHegHeN, Dat. rawnon [ay