Application Format For Individual Applicants

Application No. B P C 1 6 9 5 7 9 2 7 1 1 0 2 3 5

Application Date ** 2 7 - 0 9 - 2 0 2 3
APPLICATION FOR RETAIL OUTLET DEALERSHIP
Name of oil company Bharat Petroleum Corporation Ltd
Name of Territory Office Karur
Particulars of application fee (Rs.) 3,000.00
Transaction Number 8945688468815
Transaction Date & Time 27-09-2023 13:31:32
Payment Mode Debit Card
Are you dealer of an unviable# SKO Dealership (# Not Applicable
as per clause 4 (ix) (i) of brochure)?
Particulars of Applied location
1 Sr. No. of location in the advertisement 815
2 Name of the Location LHS ON NH 44 BETWEEN DEEVATTIPATTI TO SALEM
AIRPORT
3 District S A L E M
4 State T A M I L N A D U
5 Category S C
Eligibility certificate(s) for the category applied as above is/are available with me/us and will be submitted as and when advised by the Bharat Petroleum Corporation Ltd.
6 Advertised on 28-June-2023 In List of advertised locations in Tamilnadu, English
advertisment, Hindi Advertisment
7 Type of Site CFS
8 Type of RO Regular
9 Group of the Applicant on the Basis of land being Group 2
offered.
10 Type of applicant Proprietor
11 Applicant would be required to submit Affidavit in original as per the format given in Appendix – XA of the Brochure on intimation
by Bharat Petroleum Corporation Ltd upon selection.
11.1 Name Mrs. MUHAMIZH SELVI M
11.2 Father’s / Husband’s Name Mr. AYYASAMY P
11.3 Address 60D1 PERIYAKADAMPATTY PO SIKKAMPATTY OMALUR TK SALEM
District SALEM State TAMIL NADU Pincode 636502
Tel No. Mobile No. * 9360796890
Email ID * [email protected]
PAN EGDPM3466H
11.4 Indian Citizen Yes Resident of India as per IT Rules Yes
11.5 Gender Female
11.6 Date of Birth 06-June-1977 Age 4 6 years 0 3 months 2 1 days
Proof of age required to be submitted as and when asked by Bharat Petroleum Corporation Ltd
11.7 Document Relied for 10th Standard Board Certificate
proof of Age
11.8 Marital Status Married
11.9 Name of Spouse(if married) AYYASAMY P
11.1 Spouse employed No
0
11.1 Are you employeed in Private Sector or drawing No
1 any salary/perks/emoluments from State / Central
Goverment ?
12 Applicants Education Qualification (Minimum 10th pass or equivalent) Proof of qualifying certificate as per Eligibility criteria would
be required to be submitted as and when asked by Bharat Petroleum Corporation Ltd)
Qualification Name of Board/University/Institution Certificate/Diploma/Deg Year of Passing
ree
12.1 10th Pass or equivalent ANNAMALAI UNIVERSITY 2001
13 Land details - Group 2 ( Copy of proof of ownership of land would be required to be submitted as and when advised by Bharat
Petroleum Corporation Ltd)
Name(s) of the Relationship Date of Location of the Khasra No/Kha Dimensions of land
owner of Land / with applicant registration of land with touni/Gut Frontage in Depth in metre Area (Sq.m)
Lease holder sale deed/gift respect to No/Survey No metre
deed / lease Reference point
deed/ date of / Land mark
mutation/ date (Specify land
of Notarized mark /
Affidavit for Reference point
offer of land as and distance
per Appendix from the same)
III
Alternate Land
Plot No. 1
RAJA P SELF 13-07-2024 SALEM TO 53/2 35 60 2081
BANGALORE
BYE PASS
THUMBIPADI
VILLAGE KAD
AYAMPATTY
SALEM
Are you willing to transfer the land on sale/long lease to Bharat Petroleum Corporation Ltd Yes
If yes, at what rate(Rs.) / terms. LONG LEASE RS.5 SQ FT
The said piece of plot belonging to RAJA P has been offered to me/us for putting up a retail outlet of the Oil Company Bharat Petroleum
Corporation Ltd. The above is being given as "Firm Offer" and is for purchase / long term lease for a minimum period as per terms and
conditions as advertised by the Oil Company Bharat Petroleum Corporation Ltd.
That as per the documents available with me/us, my/our offer qualifies for being considered under "GROUP 2" as defined in clause 4 (vi) of
the Brochure for retail outlet dealer selection by the Oil Company Bharat Petroleum Corporation Ltd.
The said land, has been offered for purchase / lease / sub-lease to the oil company for a period as per the terms and condition of the advertisement published by
the Oil company Bharat Petroleum Corporation Ltd
Note: In case land belongs to member of Family / Co-owners / Others, before submission of application, notarized affidavit as per Appendix - III
should be available with the applicant, which is to be uploaded/submitted as and when asked by Oil Company Bharat Petroleum Corporation Ltd
In Case the offered land has multiple Khasra / Khatauni / Gut / Gatta / Patta / Plot / Survey Nos. etc., complete details of land to be entered in the
application.
The Site map/Layout sketch (as indicated in Appendix - V of the Brochure) indicating dimensions/ area pertaining to the part/portion of the total land where Retail
Outlet is propsed to be developed, will be uploaded by me as and when advised by Oil Company Bharat Petroleum Corporation Ltd
14 Requirement of Finance: Not Applicable
15 UNDERTAKING BY THE APPLICANT
a. I am aware that eligibility for Retail Outlet Dealership will be decided based on the information given in the application above. On verification by the Oil
Company Bharat Petroleum Corporation Ltd if it is found that the information given by me is incorrect/ false/ misrepresented then my candidature will
stand cancelled and I will be declared ineligible for the Retail Outlet Dealership.
b. I also confirm that I am in possession of the supporting documents in original in respect of the information given by me in this application and 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.
c. I am fully aware that if I am unable to provide suitable site mentioned above for setting up of the Retail Outlet as per the Oil Company' s standard layout,
then the offer / allotment of dealership made to me will be cancelled.
d. I am fully aware that I will not be appointed as Retail Outlet Dealer if I am employed. I shall have to resign from the service and produce proof of
acceptance of my resignation from my employer before issuance of Letter of Appointment.
e. I am also aware that I cannot take up any other employment nor can draw any salary/perks/emoluments from State/Central Government upon my
appointment as a dealer.
f. I confirm that neither I nor any member of my "family unit" (as per definition of family under multiple dealership norm given in Brochure) are employees
of Indian Oil Corporation Ltd or Bharat Petroleum Corporation Ltd or Hindustan Petroleum Corporation Ltd.
g. I am fully aware that If selected I shall be paying attention towards day to day working of the dealership by personally managing the affairs of the
dealership and will not be eligible for taking up any employment.
h. I undertake to fulfill the conditions of Bharat Petroleum Corporation Ltd with regard to inducting Spouse as Co-owner in the dealership if the
dealership is awarded to me.
i. That, if selected, I undertake that I will be depositing an interest free Security deposit of Rs. 300,000.00 as per the policy of the Corporation.
j. I am also aware that the same land cannot be offered by more than one applicant for a particular RO location against the same advertisement. In case it is
found that the same piece of land as offered by me has been offered by other applicant(s) for this location then my candidature for RO dealership will be
rejected/ Dealership terminated, if already appointed.
k. I confirm that I am of sound mental health & I am not totally paralyzed.
l. I confirm that I have never been convicted for any criminal offence involving moral turpitude and/or economic offences (other than freedom struggle).
 m. I hereby confirm that neither I nor any member of my Family Unit (as defined under Multiple dealership norm for individuals/non-individuals of
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.
n. I do hereby confirm that I am eligible for allotment of Retail Outlet dealership as per applicability of Multiple Dealership Norm defined under Clause
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.
o. I hereby confirm that my candidature has never been rejected/selection cancelled/dealership or distributorship terminated by any of the Oil Company for
providing false information/misrepresentation of facts/submitting false/fake documents while applying for RO/SKO-LDO Dealership / LPG
Distributorship
p. I confirm that the mobile no., e-mail Id, PAN and address mentioned in this application form belongs to me.
q. I am aware that this is only a business offer and the oil company. reserves the right to cancel the advertised location and I shall not claim any
damages/compensation from the oil company.

Declaration

I, MUHAMIZH SELVI M wife of Shri AYYASAMY P hereby confirm that the information given above is true and correct. Any wrong
information /misrepresentation/ suppression of facts will make me ineligible for this RO dealership. 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 shall be found to be untrue or
incorrect or false, the Bharat Petroleum Corporation Ltd would be within its rights to withdraw the letter of intent / terminate the dealership (if
already appointed) and that I would have no claim, whatsoever, against the Corporation for such withdrawal / termination.

Signature of applicant

**Date : 1 4 - 0 7 - 2 0 2 4 Name of applicant MUHAMIZH SELVI M

**The date mentioned in the application will be treated as date applicable for the purpose of evaluating the eligibility criteria.
Remarks: Land/Alternate land offered on 14-Jul-2024
Note:* All further communication will be done on registered email address & mobile number.

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