(Joint Venture of GAIL (India) Ltd., BPCL & Government of NCT of Delhi)

IGL Bhawan, Plot No. 4,

Community Center, Sector-9, R.K. Puram, New Delhi-110022

Reference No.: 20122256Date of Registration: 02/09/2012

A PPL I C AT I O N F O R M F O R R E G I S T R AT I O N & S U PPLY O FD O M E S T I C P I PE D N AT U R A L G A S C O N N E C T I O N

(To be filled in Block/Capital Letters Only)

I/We wish to register for domestic Piped Natural gas connection as per details mentioned below :-

NAME: Mr./Ms/Mrs. : Sumit Kumar

Father's/Husband's Name : K. K. Panday

Address : House No. : 980 / F2 Street Name :

State : UTTAR PRADESH Pincode : 201005

Landline (Office) : (Residence) :

Mobile No. : 9350641262 Email : sumeetdeep4u@gmail.com

Type of Ownership, Please tick () Owner Rented

If Rented, please submit NOC to be issued by the lawful ower of the property as specified below :-

PAYMENT DETAILS : (Non-Refundable additional charges, if applicatble to be paid on completion of the installation as per Clause

No. 2 of Customers' Rights & Obligations)

Pay Order/DD/Cheque No. Date :

Drawn on : favoring "INDRAPRASTHA GAS LIMITED"

Amount : towards Refundable Security Deposit as per the terms and conditions stated overleaf.

Date:

PAYMENT IN CASH IS

NOT ACCEPTED

Yours's Faithfully

(Signature of the Applicant)

NO OBJECTION CERTIFICATE (To be Filled by the lawful Owner)

(Applicable only if the premise is rented)

This is to certify that I, Mr./Ms./Mrs. am the lawful owner of the above-mentioned property.

I have no objection, if the tenant of the property as mentioned above, avails domestic PNG connection from Indraprastha Gas Limited

Name : Date :

Permanent Address of Owner :

Landline (Office) : (Residence) :

Mobile No. : Email :

Proof of Ownership (as enclosed) :

Signature :

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