__________ (Gas Connection Distributor Name)
__________ (Gas Connection Distributor Address)

Date: __/__/____

Subject: Request for New ________ (LPG/PNG) Gas Connection


I, _______________ (Applicant Name), son of/ daughter of/ wife of _______________ residing at __________ ( Address) hereby solemnly affirm that I am _________ (citizenship ) Citizen and my date of birth is _________ (date of birth).

I hereby declare that I am not in the possession of any LPG connection and I will use the Gas for _________ (domestic) use only.

I request you to kindly issue a ________ (LPG/PNG) new gas connection in my name.

I am enclosing _________ (undertaking/affidavit/gas connection form/KYC documents) along with the application.

Thank you,

Signature: _____________
Your Name: __________
Mobile number: _________

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