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APPLICATION FORM FOR 8 % OPA / RGGLVY / REGULAR LPG ...

APPLICATION FORM FOR 8 % OPA / RGGLVY / REGULAR LPG ...

APPLICATION FORM FOR 8 % OPA / RGGLVY / REGULAR LPG ...

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<strong>APPLICATION</strong> <strong><strong>FOR</strong>M</strong> <strong>FOR</strong> 8 % <strong>OPA</strong> / <strong>RGGLVY</strong> / <strong>REGULAR</strong> <strong>LPG</strong>DISTRIBUTORSHIP SCHEME (TICK (√) THE SCHEME APPLIED <strong>FOR</strong>)ENTESM/WIDOW/DEPEND(Tick (√ ) One)1. Name of applicant :_______________________2. Father’s Name :_______________________3. Tele No & Mobile :_______________________4. E-Mail ID (if any) :_______________________5. Address :______________________________________________6. No., Rank & Name of Service Pers :_______________________7. Relationship with Service Pers :_______________________8. Death Certificate of Service Pers :_______________________with Attributability9. Percentage of Disability with Attributability :_______________________10. Nature of pension :_______________________11. No. and date of PPO :_______________________(including Corrigendum attach copy)12. Whether employed/unemployed :_______________________13. Educational qualification (for <strong>LPG</strong> only) :_______________________14. Any other benefit taken from DGR :_______________________15. Location(s), Distt & State applied for :_______________________16. Agency (RO/<strong>LPG</strong>/KSK) :_______________________17. Name of Oil Company :_______________________18. Last date of submission of Application :_______________________With Oil CompanyI hereby certify that to the best of my knowledge the particulars given above aretrue and I have hidden nothing while stating the above facts.Dated:(Signature of applicant/representative)


AFFIDAVIT BY(ESM/WIDOW/DEPENDENT) <strong>FOR</strong> 8 % <strong>OPA</strong>/<strong>RGGLVY</strong>/<strong>REGULAR</strong><strong>LPG</strong> DISTRIBUTORSHIP SCHEME (MENTION THE CATEGORY / SCHEME APPLIED<strong>FOR</strong> ONLY)(To be typed on appropriate non-judicial stamp paper of Rs. 10/-)1. I, _______________________________________________ESM/Widow/Dependent of____________________________ S/o / D/o of__________________________________ Age ________ Years resident of________________________________________ do hereby solemnly affirm and stateas under: -(a)That I am an Indian National.(b) That I am the widow/son/daughter of Late _______________________ and notremarried (widow)/married (son/daughter).(c) That I am applying for issue of Eligibility Certificate from DGR for allotment of oilproduct agencies (<strong>LPG</strong>/RO/KSK) under ________________________Scheme asadvertised by IOCL/BPCL/HPCL/IBP) for the place/location ______________________.(d) I have neither availed of a similar concession for myself or for any of my wardsnor me or my dependent father/mother/ husband / wife / son(s) / daughter(s) has/havedealership/distributorship or hold Letter of Intent for any Oil Product Agencies of any oilcompany. I further confirm that I was never a signatory to a dealership/distributorshipagreement of any oil company, which was terminated or proved foradulteration/malpractices.(e) That I have not relinquished my right ever before and shall not reclaim in future.(in case of widows/dependents only)(f) That I fulfill requisite educational qualification as specified by the Oil Company forthe Scheme.(g) That I am unemployed / employed and will resign from the employment &produce the letter of acceptance of resignation by the employer before the issuance ofletter of intent.(h) That my annual income from all sources does not exceed Rs 2, 00,000 (RupeesTwo Lakh Only) {for ESM having Disability attributable to Military Service (Priority V of 8% of <strong>OPA</strong> scheme)}.(j) That I have gone through all the relevant clauses of Terms and Conditionsspecified by the Oil Company, understand them and shall abide by them.2. The contents of this Affidavit are true and correct to the best of my personalknowledge and belief. No part of it is false and no material has been concealed therein.If any information/declaration given by me in my application or in any documentsubmitted by me found to be untrue or false or incorrect DGR would be within its rightsto cancel the Eligibility Certificate issued to me.(Strike out whichever is not applicable)Solemnly affirmed and declared before meThis _________ day of ______________


RELINQUISHMENT DEED BY (WIDOW/DEPENDENT) <strong>FOR</strong> 8 % <strong>OPA</strong>/<strong>RGGLVY</strong> /<strong>REGULAR</strong> <strong>LPG</strong> DISTRIBUTORSHIP SCHEME(To be typed on appropriate non-judicial stamp paper of Rs. 10/-)1. I, _____________________ widow/Dependant of__________________________ Age ____ Years resident of_______________________________________ do hereby solemnly affirm and say asunder:-(a)I am an Indian National.(b) I am a widow/Dependant of___________________________________________remarried(widow)/married(son/daughter).and not(c) I have neither availed a similar concession for myself or for any of mywards/spouse nor me or my dependent mother/father/ husband / wife /son(s)/daughter(s) has/ have dealership/distributorship or hold letter of intent for any OilProduct Agencies of any oil company. I further confirm that I was never a signatory to adealership/distributorship agreement of any oil company, which was terminated forproved adulteration/malpractices.(d) I _____________________________, hereby relinquish my right for allotment ofRetail Outlet/<strong>LPG</strong>/KSK/ by IOCL/BPCL/HPCL/IBP under_______________________Scheme for the place/location ________________ to mydependent son/daughter (unmarried) (name)_________________ whose Date of Birth is__________ and is unemployed and wholly dependent on me. I have no objection inDGR issuing Eligibility Certificate to him/her for availing the facility under________________________Scheme.(e)I have not relinquished my right ever before and shall not reclaim in future.2. The contents of this Affidavit are true and correct to the best of my personalknowledge and belief. No part of it is false and no information has been concealedtherein. If any information/declaration given by me in my application or in any documentsubmitted by me found to be untrue or false or incorrect, DGR would be within its rightsto cancel the Eligibility Certificate issued to me.(Strike out whichever is not applicable)Solemnly affirmed and declared before meThis _________ day of ______________

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