Appendix – XA
I, ________________________ son of ___________________ Age _______ years residing
at __________________________________________________________. In connection
with my application for RO dealership at _______________________________________.
I do hereby solemnly affirm and say as under:
1 That I am an Indian Citizen and resident of India (as per Income Tax Rules1)
2 That my date of birth
is
That I have passed the Matriculation / 10th Std. Examination
3 conducted by Board in the year / Certificate issued by Armed
Forces as equivalent to 10th Class pass in the year
That I hereby confirm that I am eligible for allotment of Retail Outlet dealership
as per applicability of Multiple Dealership Norm defined under Clause
4 “Disqualification” in the “ Brochure for Selection of Dealers for Regular & Rural
Retail Outlets” and do not disqualify for allotment of Retail Outlet dealership
under other conditions mentioned therein.
That I hereby confirm that none of my family members (as defined under Clause
“DISQUALIFICATION” of brochure) are employees of Indian Oil Corporation
5
Ltd., Bharat Petroleum Corporation Ltd. and Hindustan Petroleum Corporation
Ltd.
That I am Unmarried
6(a) Or
That I am Married and the name of my spouse is _________________.
My name before my marriage was _______________ and after my marriage to
6(b) Shri ___________ my name has been changed to Smt. ___________________.
(only for female applicants, wherever applicable)
That my name earlier was Shri/Smt./Kum ___________________ and has been
6(c) changed to Shri/Smt./Kum ___________________ w.e.f. ________________
(Applicable in case of name change by applicant)
7 That, I am of sound mental health & I am not totally paralyzed.
That I have never been convicted for any criminal offence involving moral
8
turpitude and/or economic offences (other than freedom struggle).
I confirm that arrangement will be made for taking delivery of products on ex-
9 MI basis from the Oil Company within 4 months of intimation thereof from the
Oil Company to this effect.
I hereby confirm that neither I nor any member of my “family unit” (as defined
under Multiple dealership norm for individuals/non-individuals of
10 Disqualification criteria), was ever 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
In case I am selected for RO dealership, I undertake to develop the desired
infrastructure and facilities at the Outlet allotted as per specification and timelines
11 stipulated by the Oil Company Hindustan Petroleum Corporation Ltd in the
advertisement/LOI and also undertake to arrange the working capital for
operation of the outlet as mentioned in the Advertisement for the location.
That the details mentioned in Clause No. 9 of the application form, affidavit of
Co-owner/s (if applicable) pertaining to Land:-
a) Are true and land documents in support of the claim would be submitted as
and when advised by the Oil Company.
b) That in case I am selected for RO dealership, I undertake to arrange the said
plot as mentioned in the application form for setting up of retail outlet at the
location for which I have made the application.
c) I am aware that my claim, as above, if not supported by required documents
or in the event being found to be at variance at any stage, would result in
my application /candidature becoming invalid for further consideration by
the Oil Company.
d) I am also aware that in the event of my inability to make available the said
land required for setting up the retail outlet as required by the Oil Company
Hindustan Petroleum Corporation Limited within the period mentioned in
the LOI, then the allotment can be withdrawn and I will have no
claim/damages whatsoever against the Oil company (Name of the Oil
Company).
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e) I am also aware that in case of my selection for this RO dealership it will be
binding on me to hand over the offered land including the entry / exit /
acceleration / de-acceleration / service road duly developed up to the road
level with good earth / murrum, layer wise compacted as per standard
engineering practices to the satisfaction of OMC and I will provide retaining
wall and compound wall of minimum height 1.5 meter, designed as per site
conditions and approved by OMC engineers.
f) I am also aware that in the event of my inability to develop the requisite
infrastructure and facilities as per specification and timelines stipulated by the
Oil Company Hindustan Petroleum Corporation Limited in the
advertisement/LOI, the allotment can be withdrawn and I will have no
claim/damages whatsoever against the Oil Company Hindustan Petroleum
Corporation Limited.
g) I am also aware that in case the same piece of land offered by me for setting
up of retail outlet at location On LHS, on NH65 Within 5Km from Exit of
ORR towards Hyderabad, N.T.R District, Andhra Pradesh is offered by any
other applicant for the same purpose, my candidature for RO dealership will
be rejected.
That I hereby confirm that I will neither take up any other employment nor will
draw any salary/perks/emoluments from State/Central Government upon my
appointment as a dealer.
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If I am already employed I will resign from the employment and produce proof
of acceptance of resignation by my employer before the acceptance of Letter of
Appointment to be issued by the Oil Company.
I undertake that If selected, I shall be paying attention towards day to day
working of the dealership by personally managing the affairs of the dealership
14 and will not be eligible for taking up any employment
I am married. I undertake to fulfill the conditions of Hindustan Petroleum Oil
Corporation with regard to inducting Spouse as Co-owner in the dealership if
the dealership is awarded to me.
OR
15
I am unmarried. I undertake to inform the company of my marriage and
undertake to fulfill the conditions of Hindustan Petroleum Corporation Ltd with
regard to inducting Spouse as Coowner in the dealership within one year of my
marriage if the dealership is awarded to me
I undertake that I will observe all the relevant guidelines, with regard to
award/operation of the said dealership, issued by Indian Oil Corporation Ltd* /
16 Bharat Petroleum Corporation Ltd* / Hindustan Petroleum Corporation Ltd* /
Government of India or any other statutory body from time to time.
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 RO
dealership or in this affidavit shall be found to be untrue or incorrect or false,
Hindustan Petroleum Corporation Ltd would be within its rights to withdraw the
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letter of intent / terminate the dealership (if already appointed) and that I would
have no claim, whatsoever, against the Corporation for such withdrawal /
termination.
That, if selected, I undertake that I will be depositing an interest free Security
18 deposit of Rs. _____________ as per the policy of the Corporation.
That, if selected, I undertake that I will pay the non-refundable Fixed fee of Rs.
____ as per the policy of the Oil Company (applicable for Dealer owned sites).
(For DC sites)
OR
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That, if selected, I undertake that I will pay the non-refundable Final Bid amount
(applicable for Corporation owned sites except for Corpus fund ROs). (For CC
Sites)
I am aware that in the event of any proceedings pending against the
dealership/distributorship held by me or my “family unit” (as defined under
Multiple dealership norm for individuals/non-individuals of Disqualification
criteria) on account of critical/major irregularities for violation of Marketing
Discipline Guidelines/Dealership Agreement, Control Orders or ESMA, Court
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cases, Show Cause notices, etc., the allotment made will be conditional and
subject to the outcome of such proceedings. I understand that I will also not be
entitled for any claim, damages, etc. in case of cancellation of allotment in the
event of adverse verdict in such pending proceedings.
I hereby confirm that my candidature has never been rejected/selection
cancelled/dealership or distributorship terminated by any of the OMCs for
21 providing false information/misrepresentation of facts/submitting false/fake
documents while applying for RO/SKO-LDO Dealership / LPG Distributorship
I also confirm that I am in possession of the supporting documents in original in
respect of the information given by me in the application for RO dealership
at___________ (Location) of Indian Oi Corporation Ltd.* / Bharat Petroleum
22 Corporation Ltd. * / Hindustan Petroleum Corporation Ltd*. If selected, failure
to present these documents in original will result in cancellation of selection due
to submission of false/unsupported information in this application.
Only for applicants applying under the category of SKO dealers* (*Strike off
whatever is not applicable)
a. That I am the sole proprietor / partner of SKO dealership of ________________
(OMC Name) in the Name and style of ________ at
23 _________________(Location) operating below an average allocation of 75KL
of SKO per month during the immediate preceding 12 month prior to the
month of advertisement for the RO dealership.
b. That I have not been penalized for violation of marketing Discipline Guidelines
within last 5 years preceding the date of advertisement and / or there are no
proceeding pending against my dealership under Marketing Discipline
Guidelines, Dealership Agreement, Kerosene Control Order or ESMA.
c. That I am aware that if I am selected for the RO dealership, I will have to
surrender my SKO dealership before being appointed as RO dealer by
IOC/BPC/HPC.
If an individual stayed in India for 182 days or more in the previous financial year, he
is treated as resident of India as per Income Tax Rules irrespective of his citizenship. If
the stay is less than 182 days he is a non-resident
* 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.
Signature of Deponent
(Name in block letters)
Solemnly affirmed and declared before me. This ___________day of _______________
Signature and Seal of
Magistrate/Judge/Notary public
Note: The stamp paper should be purchased in the name of the deponent