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 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: _________