1. Preferred Area For Dealership & ReasonTown / CityStatePin CodeReasonName of Firm Proposed for DealershipRegisteredYesNoAFIf Yes - VAT/TIN No:Type of Firm:PartnershipProprietorshipPvt. Ltd.HUFLLPContact Address2. Personal InformationPrefixMr.Mrs.Ms.Mx.MissDr.Prof.Name of ApplicantDistrictStatePin CodeTelMobileEmailFaxDate of BirthEducation QualificationUnder GraduateGraduatePost GraduateProfessionalProfessionSelf EmployedServiceOthers3. Partner Details (If Any)PrefixMr.Mrs.Ms.Mx.MissDr.Prof.Name of ApplicantContact AddressDistrictStatePin CodeTelMobileEmailFaxDate of BirthEducation QualificationUnder GraduateGraduatePost GraduateProfessionalProfessionSelf EmployedServiceOthers4. Details of The Existing Profession (In case of Service)Name of The CompanyDesignation of ApplicantNature of BusinessDistrictStatePin CodeTelMobileEmail5. Details of The Current Business (If the applicant is an existing Businessman)Firm NameProductsType of BusinessTurnover (Rs.)No.of YearsAddressPhone No.MobileEmailFaxStatus of the CompanyPartnershipProprietorshipPvt. Ltd.HUFPublic Ltd.MNCAnnual Turnover / Gross Income (Rs. Lakh)LFY-2LFY-1Last FY6. Do You Have Suitable Land For The Construction Of Asian GasLPG Cylinder Storage Godown (If Any Give Details)City / Town /VillageStatePin CodeSurvey NoTotal Land Area (Please Attach the site map with dimensions)Name of the Land OwnerRelationship of the Landowner with the ApplicantIf No, within how many days / months you would be able to make arrangement for a suitable site?7. Landmark For The SiteDistance of nearest KM stone (meters)Location of the Km StoneSame side of the plotOpp. side of the plotLHS with Respect to plotRHS with Respect to plotDescription on KM stoneNearest Road Junction8. Other Site DetailsName of the Land OwnerWhat is your Relationship with the owner?Are all Document Relating to the Property Clear?YesNoAre You Willing To Give The Land/Property On Long Term Lease To IBPPL (In case of auto LPG)YesNoStatus Of Land: Agricultural / Not Agricultural (if agricultural, indicate time to convert for non agricultural use )Is Power Connection Readily Available?YesNoIf No, Indicate Time Required to Get The Power Connection (In case of auto LPG)Is There Any Electrical Wire Passing Over Your Site?YesNoHigh Tension (HT)Low Tension (LT)Is Water Connection Available Readily?YesNoIf No, Indicate Time Required to Get The Water Connection (In case of auto LPG)Are Motorable Approach Roads To Your Land/Property Existing? (If no, what is the plan for develpment)YesNo9. If You Qualify For Dealership, Who Will Be Responsible For The Operation/ Day-to-Day Business?ApplicantSelfApplicant’s RelativeNameContact No.RelationshipProfessional ManagerNameContact No.Relationship10. In case short-listed, list the infrastructure that you will provide with time line: from the date of release of LOI (Time not to exceed 90 days from date of LOI)Arrangement of land for GodownDays from date of LOIPESO initial approval for GodownDays from date of LOIGodown construction and Licence ReceiptDays from date of LOIOffice Premises ReadinessDays from date of LOIPrimary VehicleSecondary VehicleSalesman HiringCompletion of Market MappingCompletion of entire branding of office and vehiclesCompletion of all statutory requirements (eg. Vat Tin No., Excise Reg. No. etc.)Launch of Business11. Business projection: I hereby confirm to deliver the below volumes by the specified dates (month 1 being the month of first invoice)Month 1 to 3 (MT)Month 4 to 6 (MT)Month 7 to 9 (MT)Month 10 to 12 (MT)Year 2 – % GrowthYear 3 – % GrowthYear 4 – % Growth12. Enclosures (only self attested copies to be attached)Aadhar cardChoose FileNo file chosenDelete uploaded filePAN cardChoose FileNo file chosenDelete uploaded fileBank statementChoose FileNo file chosenDelete uploaded fileAddress proofChoose FileNo file chosenDelete uploaded filePartnership deed / MOAChoose FileNo file chosenDelete uploaded fileRegistration receiptChoose FileNo file chosenDelete uploaded fileApplicant's SignatureStart signing your signature hereYour browser does not support e-Signature field.Partner's SignatureStart signing your signature hereYour browser does not support e-Signature field.Partner's SignatureStart signing your signature hereYour browser does not support e-Signature field.Consent *I/we declare that the above information provided by me is true & correct. I acknowledge that Asian Gas has the right to reject my application at any stage assigning any reason whatsoever. I also acknowledge that this is only a preliminary application form and submission of the form shall not be taken as any indication that Asian Gas will enter into any agreement with the applicant. Asian Gas has the right to forfeit whole or a part of the applicable registration amount deposit in case I withdraw this application or fail to start the business as per terms & conditions of the Company. The above application & declaration is true to my knowledge and belief.Submit
