an iso 9001:2015 & 14001:2015 certified company
TRANSCRIPT
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Registered Office: 510 Aggarwal Cyber Plaza C-4,5,6 NSP District Centre DelhI North West DL 110034 IN
Corporate Office: C1 / 45Ground Floor, Vikrant Khand, Gomti NagarLucknow 226010 , Uttar Pradesh, IN
Tel : +91-0522-4233362E-mail: [email protected]: www.indiragas.com
INDIRA GAS AND PETROLEUM PRIVATE LIMITED
State
District
Block
Village
Filling up below is mandatory otherwise application will not be acceptable
Application form Number: Dealer Code:
An ISO 9001:2015 & 14001:2015 Certified Company
Name of the firm( Applied for):
APPLICATION FORM FOR DEALERSHIP / DISTRIBUTORSHIP / RETAILERSHIP / DEALER AUTO LPG
1. Separate application form to be lled & submitted for separate category / locations.2. Forms not completed in all respects & submitted without document as per company policy will be rejected.3. Submission of this form doesn’t guarantee award of Associationship. 4. The data asked for in this form is purely for the purpose to evaluate the interest of applicant about business with the company.5. The Acceptance or rejection of the application is at the sole discretion of the company. No Correspondence will be entertained in this regard.6. The company reserves the right to change, amend, add, or delete any/all clauses at any time without prior notice.7. Applicant(s) is requested to keep a photocopy of applications & documents for his / her / their records.
8. All the disputes are subject to Lucknow Jurisdiction only.
Important Instructions and Conditions:
Please Choose application purpose:
Dealership Distributorship Retailership Dealer Auto LPG
Pre- Acceptance of the T & CSignature of the Applicant (s)
1.1 Applicant 1
1.3 Address :
District PIN Code State
1.4 ADHAAR PAN
1.5 Gender M F TG Ors. Mobile +91
1.6 Date of Birth Martial Status Single / Married / Widow (er) / Divorced / Mention if any:
1.7 Qualification Please mention least qualification:
Indian Citizenyes / no
1.8 E-Mail ID Please mention your working mail id:
1.2 S/o, W/o, D/o
1.9 Applicant 2
1.11 Address :
District PIN Code State
1.12 ADHAAR PAN
1.13 Gender M F TG Ors. Mobile +91
1.14 Date of Birth Martial Status Single / Married / Widow (er) / Divorced / Mention if any:
1.15 Qualification Please mention least qualification:
Indian Citizenyes / no
1.16 E-Mail ID Please mention your working mail id:
1.10 S/o, W/o, D/o
I hereby declare that all the above information given by me is true and documented, I hereby attach supporting documents as needed. Signature of Applicant 1
I hereby declare that all the above information given by me is true and documented, I hereby attach supporting documents as needed.
Signature of Applicant 2
Enrollment Application Fee : Rs. 2500.00 (Inclusive of all Taxes)
Passport size photo of the Applicant 1
Passport size photo of the Applicant 2
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1. Personal Details of Applicant (s)
2.1 Current occupation (If individual) :
2.2 Current source of income
(if individual) :
2.3 Current business (If firm) :
2.4 Name of the firm/s (If existing) :
2.5 Type of firm : Proprietorship Partnership Public Ltd. Private Ltd.
2.6 Turnover of the company :
2.7 No. of employees employed :
2.8 Will this proposal be your primary /
additional source of income? : Primary source Additional source
2. Occupation / Business Details ( if applicable )
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3.1 Land available for development : Yes No
(If yes, please provide the following details
A) Site/Location address
Survey no./Gut no. of the plot :
Plot/Property addressVillage
Taluka
District State
National Highway No. State Highway No.
Major District Road No. City Road No.
B) Site dimensions :
Size of site [Length and Width (Mtrs.)] :
Frontage of site (Mtrs.) :
Length of plot along the road :
Total land of plot along the road :
Total land areas (Sqr . Mtrs.) :
Site plan (Please attach a sketch of the plot showing dimensions of the plot and also of the road
on which the plot is situated)
Please attach photographs of land / surrounding area
3. Site Particulars
C) Site within/ outside city limits :
Distance from nearest city/town :
4.1 Distance of nearest Km stone
from the plot (Mtrs.) :
4.2 Location of the Km stone : Same side of the plot or Opp. Side of the plot
And
LHS with respect to plot or RHS with respect to plot
4.3 Description on the Km stone :
4.4 Nearest road junction :
4. Landmark for the Site
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(Please mention the documents you will be attaching with the completed form)
1. 4.
2. 5.
3. 6.
Please submit the following documents along with application :
1) Identitiy Proof of the applicant and partner if any ( PAN Card / Voter ID / Adhaar Card )
2) Address proof of the applicant and partner if any (Ration card / Election Card / DL )
3) 3 Photograph of applicant and partner if any should be affixed on to the form
4) Blank Stamp Paper of Rs. 500/-
5) Cheque / DD / UPI / NEFT Rs. 2500.00/- ( Application Fees)
Enclosures
Documents List
Declaration
Applicant’s (s) Declaration ( Declaration is subject to the primary application and for document submission )
Applicant 1's Signature Applicant 2's Signature
Photograph Photograph
I/We hereby confirm that I have gone through the proposal carefully being capable to understand the language
and fully satisfied in all respect. I also agree with the term of non-refunding of Registration amount i.e. Rupess
I/We hereby certify that the information filled in and provided by me in this application is true and correct to the best of my knowledge and belief.
Further, I hereby assure that I will abide by the terms of the company.
-Two Thousand Five Hundred Only for the registration purpose.
Signature of Applicant 2
Date: Place:
Signature of Applicant 1
Name of Applicant 1 Name of Applicant 2