APPLICATION FOR BPCL NON DOMESTIC LPG DISTRIBUTOR

(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
Particular of application fee Rs. signature on

Demand Draft Number D D - M M - Y Y the photograph

Date

Drawn on (Name of the bank) 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 O P E N

D D - M M - Y Y Y Y IN (Please write Name of Newspaper)

5 Advertised on
6 Status of applicant: Individual Partnership (Tick as applicable )
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 /

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

D D - M M - Y Y Y Y Age as on the date of application

Strike off what is not applicable.

7.7 Marital Status Single / Married / Widow / Divorcee
Name of Spouse, If
8 married
7.9 Does any of the member (including yourself) of your ‘Family Unit’ is dealer/ distributor or LOI Yes No
If yes, then you are not
holder of any MS-HSD/ SKO-LDO dealership or LPG distributorship of any oil company.
eligible
Note : (‘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)

Name of the Location Page 1 of 8 (Signature of applicant)

 8 I. Educational Qualification

Qualification University / Institution Degree Year of Passing

i) 10th Pass
ii) Graduate Degree
iii) Post Graduate
iv) Professional Degree

Note: Marks will be awarded based on the information given by the applicant on the education qualification. On verification if it is found
that the information given above is incorrect/ false / misrepresented then the applicant's candidature will stand cancelled and will not be
eligible for distributorship.

9 In case of partnership, please give name of each of the partners and attach Proposed Partnership Deed. All partners should submit
separate applications and Application of all the partner(s) should be attached together while submission: (Please note each partner will
have to submit separate application fee and all the partners will have to appear for interview.)

Sr. No Names and address Percentage Share

10 Experience
Do you have experience of running or working in any of the establishment dealing in the following for minimum one year?
Please give full details chronologically.

Type of Experience Name and address of the Period Number of

establishment/Institution etc years

from To
Direct Sale / Home Delivered products
(including LPG distributorship)

Other Petroleum products

Any other Trade

Note: Marks will be awarded based on the information given in the application and on answers to leading questions in connection with
experience claimed during interview. On verification if it is found that the information given is incorrect/ false / misrepresented then the
applicant's candidature will stand cancelled and will not eligible for distributorship.

Name of the Location Page 2 of 8 ( Signature of applicant)

 11. Capability to Provide Infrastructure as on the Date of Application.

11(A) GODOWN FOR STORAGE OF LPG CYLINDERS OF 2000 kg

Minimum Area of plot : (13 mt. X 10 mt.)
Specifications of Land for LPG godown 130 Sq.mt.
It should be freely accessible through all weather motorable approach road and should be plain, in one
contiguous plot, free from live overhead power transmission or telephone lines. Canals / Drainage / Nallahs
should not be passing through the plot.

11(A)1 Do you have a suitable land within 20 Km from municipal/town/village limits of the Yes / No
location offered in the same State for LPG godown or LPG godown readily available
Please strike off what
Owned in your own name or in name of any member of your ‘Family Unit’. is
not applicable
Note :(‘Family Unit’ in case of married applicant, shall consist of applicant, his/her Spouse and their Unmarried
son(s)/daughter(s). In case of unmarried applicant, ‘Family Unit’ shall consist of Applicant, his/her parents and
his/her unmarried brother(s) / sister(s))

If Yes to 11A1, Provide the following details and notarized affidavit as per Annexure – 2

Name(s) of the Relationship with Date of registration of Address of the Khasra Dimensions of land * Distance
owner of Land applicant sale deed/gift deed / location of the land No/Survey from
date of for LPG Godown No Length in Breadth in location
Mutation metre metre in
km

If No to 11A1 then

11(A)2 Do you have a offer of Lease (minimum 5 yrs) from any owner of a Yes / No
Suitable land at or within 20 km from the advertised location for LPG godown .
Please strike off what is
not
applicable

If Yes to 11A2, Provide the following details.

Name(s) of the owner of Date of Address of the Khasra Dimensions of land * Distance from
Land Lease deed. location of the land No/Survey location

for LPG Godown No Length in Breadth in in km

metre metre

Note : Marks will be awarded to applicant either on ownership or offer for LPG Godown/land for LPG godown based on the information given
by the applicant . On verification if it is found that the information given above is incorrect/ false/ misrepresented then the applicant's
candidature will stand cancelled and will not be eligible for distributorship.

Name of the Location Page 3 of 8 (Signature of applicant)

11(B) SHOWROOM FOR LPG DISTRIBUTORSHIP
Specification for LPG Show Room Minimum dimension of the showroom 3 m X 4.5 m

Showroom should be located in the location advertised and should have suitable approach road

11(B)1 Do you have a suitable land in the location advertised for construction of showroom or Yes / No
showroom is readily available Owned in your own name or in the name of any member
Please strike off what is
of your ‘Family Unit’ not
applicable
Note :(‘Family Unit’ in case of married applicant, shall consist of applicant, his/her Spouse and their Unmarried
son(s)/daughter(s). In case of unmarried applicant, ‘Family Unit’ shall consist of Applicant, his/her parents and
his/her unmarried brother(s) / sister(s))

If Yes to 11B1, Provide the following details and notorised affidavit as per Annexure – 2

Land for showroom / Relationship with Date of registration of sale Address of the land Dimensions of land *
showroom is applicant deed/gift deed / date of for showroom
in the name of mutation /showroom Length in Breadth in
metre metre

If No to 11B1 then

11(B)2 Do you have a offer of Lease ( 5 yrs minimum) from any owner of the suitable land in the Yes No
location advertised for showroom or showroom. Please strike off what is not
applicable
Date of registration of Lease deed. Address of the land for
Land for showroom / showroom /showroom Dimensions of land *
showroom is in the Length in metre Breadth in metre
name of

Note: Marks will be awarded to applicant either on ownership or firm offer for showroom/land for showroom based on the information given by
the applicant. On verification if it is found that the information given above is incorrect/ false/ misrepresented then the applicant's candidature will
stand cancelled and will not be eligible distributorship.

12. Have you ever been convicted or charges have been framed by Court of Law for any criminal offence involving moral turpitude and / or economic
offence (other than freedom struggle)? (If yes you are not eligible to apply.) Yes/ No (Please strike off what is not applicable)

Name of the Location Page 4 of 8 ( Signature of applicant)

13. DECLARATION BY THE APPLICANT

I am aware that inter se suitability of candidates will be decided by evaluation of candidates on the document based marks and
interaction ( interview). Evaluation on document based marks will be done based on the information given by me/us in this
application. On verification by the Oil Company if it is found that the information given by me/us is incorrect/ false/ misrepresented
then my/our candidature will stand cancelled and I/We will be declared ineligible for LPG Distributorship. I also confirm that I am in
possession of the supporting documents in original for 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
documents.

I am fully aware that if I am unable to make Godown duly approved by the Chief Controller of Explosives on the land/godown
indicated in the application and or Showroom as per the oil company’s standard layout on the land/shop indicated in the
application herein above after selection then the allotment of distributorship made to me will automatically stand cancelled.

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.

I have read the conditions for the distributorship mentioned in the advertisement and confirm that I fulfill the eligibility criteria
for the LPG distributorship I have applied in this application.

Name of the Location Page 5 of 8 ( Signature of applicant)

 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

D D - M M - Y Y Y Y Name of applicant
Date :

Check list for Applicants

CHECK
S.No Document / Activity to be checked
1. DD attached - verify amount, drawn in favour of concerned Oil Company and payable at
2. Photograph pasted and signature across photograph

3. Notarized Affidavit in original as per format given in Appendix - 1 attached.

4. Notarized Affidavit in original as per Appendix -2 as applicable

5. Undertaking in at the end of application duly signed with name, date and place

6. All pages of application are numbered and signed

7. Total Number of pages

8. The Application is complete in all respect

Name of the Location ( Signature of applicant)

Page 6 of 8
 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 10th examination from recognized School / Institution in the year* y y y y

and / or

That I have passed & completed the course of Graduate / Post-Graduate in the year* y y y y
and /or

That I have passed & completed the Professional Degree 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 Non Domestic LPG Distributorship or in this affidavit shall be found to be untrue or
incorrect or false, the Bharat 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)

Name of the Location Page 7 of 8 ( Signature of applicant)

 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 No n - d om es tic
LPG distributorship of BPC at _(location) under ' OPEN ' 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 N o n - D o m e s t i c
LPG distributorship of BPC at (location) under 'OPEN' category against
the advertisement made in news paper dated

* Strike off whichever is not applicable.

2. That in case he/she is selected for Non- Domestic LPG distributorship I have no objection for construction of godown /
showroom on the land specified in item no 11(A) 1& 11(B) 1 in my name.

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

Name of the Location Page 8 of 8 ( Signature of applicant)