Declaration
Form For New Gas Connection
(For
Domestic Use)
DECLARATION
I, _________ son of
_________, age _________, Resident of _________ desire to take domestic LPG
connection in my name & affirm as under:-
1. That I am
_________ Citizen.
2. That my
date of birth is _________.
3. That
neither I nor any other member of the household possesses any LPG connection
from _________ for domestic use.
4. That
I am enclosing a copy of ration card no. _________ including my name.
5. I confirm
that the LPG connection issued to me will be used in my above mentioned address
and for domestic cooking purpose only & I shall abide by all terms
governing its use.
6. That I
shall not any other LPG installations in the same kitchen.
7. That as and
when second cylinder issued to me against this connection the same will also be
used in the same kitchen and with the original installation
I hereby declare that whatever
has been stated above is true to the best of my knowledge correct and nothing
material has been concealed there from.
Date: _________
Signature:
_________
Place:
_________
Name:
_________
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