Appendix - 1
(NOTORISED AFFIDAVIT)
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
I, son/daughter/wife of Age
years residing at do hereby solemnly affirm and say as under:
1. That I am an Indian Citizen and residing in India.
2. That my date of birth dd mm yyyy is (in words ____________ )
3. That I passed Xth Standard in the year*
4. That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried
sister(s) have dealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO
dealership or LPG distributorship or GRAMIN VITRAK of any PSU Oil Company.
OR
That I am married and name of my spouse is . That neither I nor my spouse,
unmarried son(s)/unmarried daughter(s) have dealership/distributorship or hold letter of Intent for
Retail Outlet or SKO-LDO dealership or LPG distributorship or GRAMIN VITRAK of any PSU
Oil Company.
OR
That I am widow/widower. That neither I nor my unmarried son(s)/unmarried daughter(s) have
dealership/distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or LPG
distributorship of any PSU Oil Company.
OR
That I am divorcee. That neither I, nor unmarried son(s)/unmarried daughter(s) (whose custody is
given to me) have dealership/distributorship or hold letter of Intent for Retail Outlet or SKO-LDO
dealership or LPG distributorship of any PSU Oil Company.
5. That I hereby confirm that none of my family members as defined in Brochure are employees of
Oil Marketing Companies.
6. That I am of sound physical and mental health.
7. That I have never been convicted nor charges have ever been framed against me by any Court of
Law for any criminal offences involving moral turpitude and/or economic offences (other than
freedom struggle).
8. That I hereby confirm that I was never a signatory to dealership/distributorship agreement of any
PSU Oil Company, which was terminated for proven malpractices and/or for violations of
provisions of the Marketing Discipline Guidelines. I also confirm that I have not resigned from
Sole proprietorship of any dealership/distributorship of any PSU Oil company in order to transfer
the dealership/distributorship in favour of my family members/s (as defined in the
Dealer/Distributor Selection Guidelines).
9. For Applicants applying under the category of SKO dealers * (a) That I am the sole proprietor of
SKO dealership of (OMC name) in the Name & Style of at
(location) operating below an average allocation of 75 KL of SKO per month during the
immediate preceding 12 months prior to the month of advertisement for LPG Distributorship.
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3. I hereby verify that what has been stated above is true and correct to the best of my knowledge, and
nothing has been concealed therefrom.
I also confirm that I have not offered this piece of land to any other person for the above purpose.
Name(s) Signature
Solemnly affirmed and declared before me
This ____________________ day of ________________
Signature and Seal of Signature of person making affidavit
Magistrate/Judge/Notary public (Name in block letters)
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