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NOTIFICATION FOR APPOINTMENT UNDER THE RAJIV GANDHI GRAMIN LPG VITARAK YOJANA FOR ORISSA
1. INDIAN OIL CORPORATION LTD (IOCL), BHARAT PETROLEUM CORPORATION LTD brother(s) and unmarried sister(s). In case of divorcee, ‘Family Unit’ shall consist of individual 10. CORPUS FUND SCHEME - Financial Assistance to Candidates Selected for RGGLV
(BPCL) and HINDUSTAN PETROLEUM CORPORATION LTD (HPCL) propose to appoint concerned, unmarried son(s)/unmarried daughter(s) whose custody is given to him/her. In Locations Reserved Under SC/ST Category.
RAJIV GANDHI GRAMIN LPG VITARAK YOJANA (RGGLV) under various categories at case of widow/widower, ‘Family Unit’ shall consist of individual concerned, unmarried son(s)/ Candidate Selected for RGGLV locations reserved under SC/ST category will be provided a
locations specified below from amongst the candidates belonging to different categories unmarried daughter(s). secured loan of Rs. One Lakh for construction of Godown/other facilities by the concerned
mentioned herein in the State of Orissa: (f) have minimum total amount of Rs 2 lakhs put together from Saving accounts in Bank (as Oil Company. This amount will be recovered on per refill basis at the rate of 20% of distributor’s
Sl. Oil Company Name of RGGLV Location District Category on date of application), free and un-encumbered fixed deposits in scheduled banks, commission for 14.2 kg cylinders as per policy.
No. (Town/Village(s)) Kisan Vikas Patra, NSC, bonds, any other investment, etc in the name of self or family For RGGLV locations reserved under SC/ST category, the concerned Oil Company will provide
1 IOC Simulia Baleswar CC members of the ‘Family Unit’ as defined above. (In case of RGGLV locations reserved adequate working capital loan for operation of the RGGLV at an interest rate of 11% per
2 IOC Khaira Baleswar O under ‘SC/ST’ category, applicants with less than Rs 2 lakhs are also eligible to apply). annum on reducing balance. Both, the working capital loan as well as interest will be recovered
For evaluation purpose, marks will be awarded to applicants of all categories based on in 100 equal monthly installments from 13th month of commissioning of the RGGLV.
3 IOC Ambadoni Baragarh SC
the amount mentioned in the application.
4 IOC Jharbandh Baragarh O 11. SECURITY DEPOSIT
(g) own a suitable land (plot) of minimum 20 metre X 24 metre in dimension at the advertised
5 IOC Gaisilat Baragarh CC The selected candidate before being issued the appointment letter shall have to deposit
RGGLV location for construction of LPG cylinder Storage Godown.
interest free refundable security deposit of Rs. 2 lakhs with the concerned Oil Company. The
6 IOC Tentulikhunti Bolangir O Own means having clear ownership title of the property in the name of applicant/family member Concerned Oil Company will have the right to adjust any dues to it from this amount at the
7 IOC Belpada Bolangir ST of the ‘Family Unit’ as defined in multiple dealership/distributorship norm. In case of ownership/ time of resignation/ termination. However, in case of termination of the RGGLV on account of
8 IOC Khaparakhol Bolangir O co-ownership by family member, consent letter from the family member will be required. proven malpractice, the said security deposit shall be forfeited.
9 IOC Turkela Bolangir CC Land for construction of Godown will be considered suitable, if it is freely accessible through 12. PERSONAL SUPERVISION
all weather motorable approach road (public road or private road of the applicant connecting
10 IOC Dhamnagar Bhadrak O A person selected for RGGLV should personally manage it. He/she will not be eligible for
to the public road) and should be plain, in one contiguous plot, free from live overhead power
11 IOC Barkot Deogarh O transmission or telephone lines. Pipelines / Canals / Drainage / Nallahs should not be passing taking up any other employment. If the selected person is already employed he/she will have
to resign from the employment & produce the letter of acceptance of resignation by the
12 IOC Raimal Deogarh CC through the plot.
employer before the issuance of Letter of Appointment by the Oil Company.
13 IOC Dharamshala Jajpur ST (h) be physically and mentally sound to be able to run the business
13. COMMISSIONING OF RGGLV
14 IOC Laikera Jharsuguda O (i) neither have been convicted nor charges been framed by any Court of Law for any
criminal offence involving moral turpitude/ economic offences. Field verification will be carried out for the selected candidate and if information given in the
15 IOC Champua Keonjhar CC application by the candidate is found to be correct, Letter of Intent will be issued. Selected
16 IOC Jhumpura Keonjhar O (j) not be a signatory to distributorship/dealerships agreement, terminated on account of candidate who has been given the ‘Letter of Intent’ (LOI) would be required to fulfil the terms
proven cases of malpractice/adulteration of any Oil Company. and conditions as contained therein, so as to commission the RGGLV within the stipulated
17 IOC Telkoi Keonjhar SC
4 SPECIFIC ELIGIBILITY CRITERIA FOR DIFFERENT CATEGORIES : time period. Before commissioning, Letter of Appointment will be given and RGGLV agreement
18 IOC Koksora Kalahandi ST
a. Open Category (O) shall be executed. The duration of the agreement will be initially for five years, renewable for
19 IOC Golmunda Kalahandi O every five years thereafter, subject to the satisfactory performance of the RGGLV.
20 IOC Madanpur-Rampur (Madanpur) Kalahandi CC Candidate fulfilling common eligibility criteria can apply under ‘Open’ category.
14. GENERAL
21 IOC Lanjigarah Kalahandi O b. Scheduled Caste/ Scheduled Tribe Category (SC/ST):
(a) The company reserves the right to cancel/withdraw/amend this advertisement or extend
22 IOC Bangiriposi Mayurbhanj O The candidates belonging to castes/tribes recognised as Scheduled Castes/ Scheduled Tribes the due date at its sole discretion without assigning any reason.
(SC/ST) under the Constitution of India will be eligible.
23 IOC Bahalada Mayurbhanj CC (b) Application for RGGLV can be submitted on a plain paper hand written neatly or typed as
The candidates will be required to submit along with application a certificate issued by the per format given in the advertisement. After submission of application, no addition /
24 IOC Komna Nuapada O
competent authority notified by the Government of India certifying that the candidate belongs deletion/ alteration will be permitted. Applicant should number all pages of the application
25 IOC Rengali Sambalpur O to Scheduled Caste /Scheduled Tribe. including affidavits attached therewith and sign on each page. All affidavits have to be
26 IOC Gobindapur - Bamra Sambalpur ST c. Combined Category (CC) submitted in original along with the application.
27 IOC Manesar Sambalpur O Applicants belonging to any of the following categories can apply for RGGLV under (c) Only those documents that are sought in the Application format should be submitted
28 IOC Balisankar Sundergarh CC ‘Combined Category’. along with the application. Any additional document will not be considered.
29 IOC Kutura Sundergarh O i) Defence Personnel Category (DP): (d) Applications received after the cut-off date including postal delay, and those without
accompanying valid documents including application processing fee or incomplete in
30 IOC Lafripada Sundergarh SC Defence Personnel means personnel of armed forces (viz. Army, Navy, Airforce) and will any respect will not be considered. No correspondence will be entertained by respective
31 IOC Himagiri Sundergarh O cover widows/dependents of those who died in war, war disabled/disabled on duty, widows/ Oil Company in such cases.
32 IOC Bishra Sundergarh CC dependent of those members of Armed Forces who died in harness due to attributable causes
(e) Except for locations advertised under ‘Open’ category, the eligibility certificate for the
and disabled in peace due to attributable causes.
33 IOC Koida Sundergarh O respective categories viz – ‘SC/ST’, and Combined Category (CC) consisting of Defence
Candidate applying under this Category should produce Eligibility Certificate issued from Personnel (DP), Paramilitary/Police/Government Personnel (PMP), Outstanding Sports
34 IOC Lahunipada Sundergarh ST
Directorate General of Resettlement (DGR), Ministry of Defence, and Government of India Personnel (OSP), and Physically Handicapped (PH) has to be submitted.
35 IOC Basta Baleswar O sponsoring the candidate for the RGGLV for which he/she has applied. Certificate of eligibility (f) If any statement made in the application or in the documents enclosed therewith or
36 IOC Remuna Baleswar SC issued for one RGGLV is not valid for another RGGLV and therefore a candidate can be subsequently submitted in pursuance of the application by the candidate at any stage is
37 IOC Veden Baragarh O considered to be eligible only if he/she has been sponsored for the particular location with found to be incorrect or false, the candidature and application is liable to be rejected
reference to current advertisement without assigning any reason and in case the applicant has been appointed as a RGGLV,
38 IOC Deogaon Bolangir CC
ii) Paramilitary/Police/Government Personnel Category (PMP): the same is liable to be terminated. In such cases the candidate/RGGLV shall have no
39 IOC Puintola Bolangir O claim whatsoever against the respective Oil Company.
The personnel of Paramilitary/Police including persons having served in BSF, CRPF, CISF,
40 IOC Muribahal Bolangir ST ITBP, Railway Protection Force, Special Reserved Police, Special Armed Police, Coast Guards, (g) Applicants should provide only that information against various items of application, for
41 IOC Teleibani Deogarh O Assam Rifles etc. as designated by Central Government and Police Forces of the States, which they are in possession of supporting documents in original as on the date of
42 IOC Biramaharajpur sadar Sonepur CC Customs and Central Excise Department, Narcotics Control Bureau, Enforcement Directorate, submission of application. Failure to present these documents in original at the time of
Economic Intelligence Bureau, Directorate General of Anti-Evasion and Directorate of Revenue verification will result in cancellation of selection due to submission of false/unsupported
43 IOC Tarbha Sonepur O
Intelligence and those serving in different Departments of Central/State Governments who information.
44 IOC Narla Kalahandi O are incapacitated or disabled while performing their duties will be eligible under this category. (h) The envelope containing the application, duly filled in, should be superscribed as under
45 IOC Dharmagarh sadar Kalahandi CC In case of death, while performing duties, their widows/ dependants will also be eligible under “This application is for Rajiv Gandhi Gramin LPG Vitrak Yojana at ...........................
46 IOC Jasipur Mayurbhanj CC this category. (location) of ......................... (Name of Oil Company)”.
47 IOC Thakurmunda Mayurbhanj O Candidate applying under this category should attach a copy of relevant certificate from the (i) This is purely a business proposition and not an application for job in the respective Oil
48 IOC Bisoi Mayurbhanj SC concerned Organisation/Govt Department signed by the Head of the Office or an Officer not Company and has normal business risks and also does not guarantee any assured
below the rank of Under Secretary to the Government. returns or profits.
49 IOC Nuapada sadar Nuapada ST
iii) Physically Handicapped Category (PH) (j) This is only an application and not an offer of RGGLV.
50 IOC Tangarpali Sundergarh O
Candidates would be considered eligible under this category in case the candidates are APPLICATION FORM
51 IOC Bonaigarh Sundergarh ST
orthopaedically handicapped to the extent of minimum of 40% permanent (partial) disability (FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN)
52 BPC Chandrapur Rayagada ST of either upper or lower limbs; or 50% permanent (partial) disability of both upper and lower PLEASE READ GENERAL INSTRUCTION TO THE CANDIDATES BEFORE MAKING THE APPLICATION
53 BPC R.Udayagiri Gajapati O limbs together. For this purpose, the standards contained in the ‘Manual for Orthopaedic
54 BPC Jagannath prasad Ganjam SC Surgeon in evaluating Permanent Physically Impairment’ brought out by the American Academy For Office Use D D - M M - Y Y Passport size
of Orthopaedic Surgeons, USA and published on its behalf by the Artificial Limbs Manufacturing photograph
55 BPC Sankhemundi Ganjam O Not to be filled by applicant Office Code Serial No. Date of receipt of application with specimen
Corporation of India, G.T. Road, Kanpur, shall apply. signature on
56 BPC Kukudakhandi Ganjam CC APPLICATION FOR RAJIV GANDHI GRAMIN LPG VITRAK YOJANA OF the
Deaf, Dumb and Blind persons with minimum degree of 40% disability will also be eligible to photograph
57 BPC Rasulpur Jajpur O Please write name of Oil Company of the location (BPC or IOC or HPC)
apply for all RGGLVs/dealership under this category. However, totally blind persons will not
58 BPC Tikabali Kandhamal O be eligible. Particular of application fee Rs.
59 BPC Kotagarh Kandhamal SC Candidate applying under this category should produce a certificate (as per the standard Demand Draft Number Date D D - M M - Y Y
60 BPC G.Udayagiri Kandhamal O format given the application format) issued by a Medical Board duly constituted by the Central Drawn on (name of the bank) Payable At
/ State Government as per the Gazette of India Extraordinary New Delhi, No 154 dated June In favour of (Full name of the oil company)
61 BPC Phiringia Kandhamal CC
13, 2001 on Guidelines for evaluation of various disabilities and procedure for certification. (Enclose Application processing fee of Rs. 1000/- (One thousand only) for all applicants except
62 BPC Daringibadi Kandhamal O
iv) Outstanding Sports Persons Category (OSP) SC/ST candidate. Application processing fee for SC/ST candidates in Rs. 500/- (Five hundred)
63 BPC Khandapada Nayagarh SC on enclosing SC/ST certificate)
The following persons will be eligible :
64 BPC Kakatpur Puri CC
(i) Arjuna/Khel Ratna Awardees. 1. Name of the RGGLV Location
65 BPC Shergarh Ganjam ST 2. Gram Panchayat
(ii) Winners of Medals at Olympics/Asian/Commonwealth Games and Recognised World
66 BPC Dharakot Ganjam O Champions/World Championships. 3. Rev. Distt.
67 BPC Korei Jajpur O (iii) National Champions (First position) under the Recognised National Championships. 4. State
68 BPC Balichandrapur Jajpur ST (iv) National Adventure Awardees. 5. Category
69 BPC Chatia Jajpur O Candidate applying under this category should produce a certificate from the Recognised
OP, SC/ST, Combine Category (CC) Consisting of (DP/PMP/PH/OSP)
70 BPC Balianta Khurda O National Federation Organising National Championships (as recognised by Department of
Youth Affairs and Sports, Govt of India) or from the Dept of Youth Affairs and Sports, Govt of Please attach copy of certificates as proof from the respective competent authorities
71 BPC Pichkuli Khurda ST as mentioned in the eligibility criteria. Not Applicable for locations under ‘Open’ category.
India.
72 BPC Bolgarh Khurda O 6. Advertised on D D - M M - Y Y Y Y in (Please write Name of Newspaper)
5. Application can be made on plain paper (preferably typed) as per the prescribed format
73 BPC Nuagaon Nayagarh CC given in this advertisement. 7. Particulars of Applicant - Enclose Affidavit as per format given in Appendix ‘A’)
74 BPC Gania Nayagarh O 6. APPLICATION PROCESSING FEE: Application to be submitted along with non-refundable 7.1 Name
75 BPC Sakhi Gopal Puri O fee of Rs 1000 (Rupees One thousand only) and in case of SC/ST candidates (SC/ST certificate First Name Middle name Surname
76 BPC Kanas Puri CC to be attached) Rs 500/- (Rupees five hundred). 7.2 Father’s/ S H R I
77 HPC Kishorenagar Angul O 7. APPLICATION (AS PER FORMAT GIVEN IN THIS ADVERTISEMENT) for RGGLV along Husband’s Name Title First Name Middle Name Surname
78 HPC Narsinghpur Cuttack SC with enclosures complete in all respect and Non-refundable fee by a Demand Draft/Pay 7.3 Address
Order drawn on any Scheduled Bank must be submitted so as to reach the office address
79 HPC Gandia Dhenkanal O mentioned below before the close of office on 20.11.2009
80 HPC Odapada Dhenkanal ST Advertised locations Demand Draft/Pay Payable at Office Address for submitting
81 HPC Kankadahada Dhenkanal O Pin Code
Sr. No Order drawn on any application along with
82 HPC Parjang Dhenkanal CC Scheduled Bank enclosures and application Telephone No. E-mail
From To Drawn in favour of processing fee
83 HPC Ali Kendrapara O STD code Telephone Number
84 HPC Kendrapada-Indupur Kendrapara CC 01 51 IndianOil Corporation Bhubaneswar Area Manager, Indane Area Office, 7.4 Indian Citizen Yes No Resident of (Name of the village)
85 HPC Marshaghai Kendrapara O Limited (MD) IndianOil Corporation Limited (MD), Revenue District
Alok Bharti (3rd Floor), Bhubaneswar- State
86 HPC Baipariguda Koraput ST
751007, Ph : 0674-2542241/2542986
87 HPC Pattangi Koraput O 7.5 Gender Male / Female
52 76 Bharat Petroleum Bhubaneswar Territory Manager (LPG), Bharat
88 HPC Raikia Kandhamal CC Corporation Limited Petroleum Corporation Limited, LPG 7.6 Date of Birth D D - MM - Y Y Y Y Age Years Months Days
89 HPC Balimela Malkangiri ST Bottling Plant & Territory Office, Plot 7.7 Marital Status Single / Married / Widow / Widower / Divorcee
90 HPC Dabugaon Nabarangpur O no.33, Industrial Estate, PO : PN 7.8 Name of Spouse
College, Khurda, ORISSA – 752057
91 HPC Kaniha Angul O 8 Educational Qualification:
Ph : 06755-223324/25
92 HPC Gobra (Talcher Sadar) Angul CC Qualification Board/University Year of Passing
77 101 Hindustan Petroleum Bhubaneswar Sr.Regional Manager, Hindustan
93 HPC Kalapathara Cuttack O i. Graduate
Corporation Limited Petroleum Corporation Limited,
94 HPC Naraj Cuttack CC Bhubaneswar LPG Regional Office, ii. Senior Secondary i.e. (10+2) CBSE
95 HPC Raghunathpur Jagatsinghpur CC Jatni LPG Bottling Plant, PO : or equivalent from recognised Board
96 HPC Tirtol Jagatsinghpur O Jatni Dist : Khurda, Pin-752050 iii. Matriculation i.e. Xth Standard examination
Ph : 0674-2492912 or equivalent from recognised Board
97 HPC Erasama Jagatsinghpur SC
98 HPC Balikuda Jagatsinghpur O 8. SELECTION PROCESS AND EVALUATION CRITERIA Note : Marks will be awarded based on the information given by the applicant on the
All the applicants satisfying the eligibility criteria will be evaluated out of total 100 marks educational qualification. On verification if it is found that the information given above is
99 HPC Navgoan Jagatsinghpur CC incorrect/false/misrepresented then the applicant's candidature will stand cancelled and
based on information given in the application. The evaluation will be done on the following
100 HPC Derabisi Kendrapara SC will not be eligible for RGGLV.
parameters:
101 HPC Papadahandi Nabarangpur O 9. Details of land for construction of LPG godown & showroom
Sl. No Parameter Max marks
Abbreviations used in ‘‘Category’’ column are : SC/ST - Scheduled Caste/ Scheduled The land should be suitable, in contiguous plot, freely accessible through all weather
1. Financial Capability 50
Tribe Category, O - Open Category, CC - Combined Category consists of (I) Defence motorable approach road. The plot should be free from live overhead power transmission/
Personnel (DP), (II) Paramilitary/ Police/ Government Personnel (PMP), (III) Physically 2. Income 10 telephone lines. Pipelines/Canals/Drainage/Nullahs/Public Roads should not pass through
Handicapped (PH), (IV) Outstanding Sports Persons (OSP). 3. Educational Qualification 40 the plot. The land should be in advertised location. Dimension of the land should be -
2 Only Individuals are eligible to apply. However, on appointment all RGGLVs will be jointly in minimum 20 metre X 24 metre.
Selection for RGGLV will be done by draw of lot amongst all eligible applicants securing
the names of applicant and his/her spouse (i.e wife/husband will be co-owner of RGGLVs). In minimum qualifying marks. Minimum qualifying marks is 60% for RGGLVs reserved under Do you own a suitable land at advertised location for
case, the applicant is unmarried/divorcee/widow/widower, an undertaking will be required to SC/ST category and minimum 80% marks for all other category locations. LPG godown & showroom?
be given that after marriage/re-marriage, spouse will be made co-owner. There will be no (Own means having clear ownership title of the property in the
Detailed guidelines including detailed criteria for evaluation and draw of lot is given in the
educational qualification requirement for spouse. name of applicant/family member of the ‘Family Unit’. Family
Brochure, which can be collected personally from the address mentioned at para 7 above at
3 COMMON ELIGIBILITY CRITERIA FOR ALL CATEGORIES : a cost of Rs.50/-. It is also available on the website of respective oil companies –www.iocl.com; Unit’ of a married applicant, shall consist of self, applicant's
Applicant applying for RGGLV should www.ebharatgas.com; www.bharatpetroleum.in and www.hindustanpetroleum.com spouse and unmarried son(s)/daughter(s) and ‘Family Unit’ of YES / NO
a unmarried Applicant, shall consist of self, applicant's parents
(a) be an Indian citizen. 9. BASIC INFRASTRUCTURE FACILITIES REQUIRED FOR OPERATION OF RGGLV – LPG
and applicant's unmarried brother(s)/ sister(s) for the purpose of
Storage Godown and Showroom.
(b) be a resident of the town/village(s) of the advertised RGGLV location. this entire application. In case of family member, consent letter
RGGLV would require a storage Godown approved and licensed by Chief Controller of from the family member will be required.)
(c) have passed minimum Xth Standard examination or equivalent from recognised Board.
Explosives of Petroleum and Explosives Safety Organisation (PESO) for storage of LPG in
(d) be not less than 21 years and not more than 45 years in age as on the date of application. If ‘NO’, Applicant is not eligible Please strike off what is not applicable
cylinders. A showroom of the dimensions 2.6 m X 3 m is required to be constructed near the
(e) fulfil Multiple Dealership/Distributorship norm. Godown or operated from an existing nearby shop. Provide the following details. In case land belongs to member of ‘Family Unit’, attach
notorised affidavit as per Appendix-D
Multiple Dealership/Distributorship norms means that the applicant or any other member of For construction of Godown, land should be of Minimum Dimensions 20 metre X 24 metre. It
‘family unit’ should not hold a dealership/distributorship/RGGLV or Letter of Intent (LOI) for a should be freely accessible through all weather motorable approach road (public road or Name(s) of the Relationship Date of registration Address of the Khasra Dimension of land*
dealership/distributorship/RGGLV of a PSU Oil Company i.e only one Retail Outlet/SKO- private road of the applicant connecting to the public road) and should be plain, in one owner of Land with applicant of sale deed/gift/ location of the No/Survey
LDO dealership/LPG distributorship/RGGLV of PSU Oil Company will be allowed to a ‘Family contiguous plot, free from live overhead power transmission or telephone lines. Canals / date of mutation land or LPG No Length in Breadth in
Drainage/Nallahs should not be passing through the plot Godown Metre Metre
Unit’.
‘Family Unit’ in case of married person/ applicant, shall consist of individual concerned, his/ RGGLV will not be required to deliver LPG cylinders at the residence of the customers. LPG
her Spouse and their unmarried son(s)/daughter(s). In case of unmarried person/ applicant, cylinders will be given to the customers from the authorised licensed LPG Godown at the *Give the dimensions of the plot that will be used for proposed godown out of
‘Family Unit’ shall consist of individual concerned, his/her parents and his/her unmarried Retail Selling Price(RSP). the total land owned by the applicant.
Contd. to next page
Contd. from previous page
proof in support of the income indicated. Appendix - C
10 Financial Capability
e) Income from agriculture : A certificate from (NOTARISED AFFIDAVIT)
Note : Marks will be awarded to the applicant on Financial Capability based on the information Mamlatdar/Tehsildar stating out clearly the (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
given below by the applicant on Annual Income, Amount in Savings Bank Account/ Investments, location of the agricultural land the income (To be given by the family member as defined in eligibility criteria other than applicant)
Value of Assets and Amount of loan from Banks/Financial Institution. On verification, if it is there from
found that the information given by the applicant is incorrect/ false/ misrepresented then the I, ........................................................... son/wife/daughter of ............................................ Age
10.2 Amount in the Saving Account in the name of Notorised Affidavit as per
applicant's candidature will stand cancelled and the candidate will be ineligible for this RGGLV. .............................. years resident of .................. do hereby solemnly affirm and say as under :
self & the member(s) of the "Family Unit" as Appendix-C and Savings Bank
10.1 Annual Income of Last Financial Year : Rs on the date of application only will be Accounts Statement/Pass Book 1. That I am unmarried and my father*/mother*/unmarried brother*/unmarried sister* (Mr/Ms)
considered. Amount maintained in the joint from which amount as on the date ................................................................ (name) has applied for RGGLV of IOC*/BPC*/HPC*
Amount in words account with member(s) outside the of application can be verified at .................................. (location) under ‘....................’ category against the advertisement
If you are income tax payee/payer mention PAN mumber "Family Unit" should not be mentioned made in ............................ news paper dated ...............................
Income pertaining to last Financial Year should be given. Attach notorised affidavit as 10.3 Investment in Fixed Deposit/Bonds/NSCs/ Notorised Affidavit as per OR
Mutual Funds/Shares/ULIP value as on Date Appendix-C and original
per Appendix-B That I am married and my unmarried son*/unmarried daughter*/wife*/husband* (Mr/Ms)
of Advertisement in the name of self and investment documents based on
10.2 AMOUNT IN SAVINGS BANK ACCOUNT as on the date of application in the name of member of the "Family unit". which amounts has been ................................................................. (name) has applied for RGGLV of IOC*/BPC*/HPC*
applicant and members of 'family unit'. For the amount mentioned against the member of Amount maintained in the joint account with mentioned in the application at .................................. (location) under ‘.......................’ category against the advertisement
'family unit' marks will be awarded based on the amount mentioned in the affidavit made by member(s) outside the "Family Unit" should made in .........................news paper dated ..........................
member(s) of 'family unit' the as per format given in Appendix-C. not be mentioned. and will not be considered. * Strike off whichever is not applicable.
Sl. Name of S.B.A/C Name of Relation with Amount as on date Fixed Deposit/Term Deposit etc in Bank- Bank Statement or letter from the
2. That in case he/she is selected for RGGLV I will provide financial assistance to the extent of
No. Bank No. account holder(s) applicant of applicatiion amount as on the date of advertisement should Bankers certifying the amount in
Rs ...................................... which is mentioned at Item no.10 under my name in the application
be taken from the Bank FD/Term deposit as on the date
1. Rs. • submitted by (Mr/Ms) ........................................... for RGGLV of IOC*/BPC*/HPC* at
of advertisement
2. Rs. • ............................................
Investments in Mutual Funds/listed shares/ULIP Value on the date of
3. Rs. • based on the NAV on the date of advertisement. advertisement as certified by the 3. That in case he/she is selected for RGGLV I have no objection for construction of godown/
4. Rs. • Government Approved Valuer or showroom on the land specified in item no 9 in my name.
Total Rs. • the concerned financial institution/ I hereby verify that what has been stated above is true and correct to the best of my knowledge,
certified by Chattered Accountant and nothing has been concealed therefrom
Total amount in words
Amount of money which applicant can get on Certificate from the Insurance
10.3 FIXED DEPOSIT/NSC/SHARES/MF ETC as on date of advertisement in the name of surrender of Insurance policy or as loan against Company Solemnly affirmed and declared before me
applicant and members of ‘Family Unit’. Attach affidavit as per format given in the policy as on the date of advertisment. This ...................... day of .....................
Annexure-C from member(s) of ‘Family Unit’. 10.4 Other assets/Property( immovable) in the name Valuation certificate by Govt. Signature and Seal of Signature of Deponent
Sl. Type of Doccument Name(s) Relation Initial Value (Amount) as on the of the member of the "Family Unit" as on the Approved Valuer should give
No. Investment Reference of the with investment date of advertisement date of advertisement. Assets/Property in the the the Value of assets as Magistrate/Judge/Notary public Relationship with applicant
FD/NSC/ Number holder applicant Amount name of joint account of the member(s) outside prevailing on the date of
Shares/ with date the "Family Unit" should not be mentioned. advertisement. Date of Valuation Appendix - D
MF etc (Note: Gold should not be included). The Certificate should between (Format for obtaining Credit worthiness certificate from the Bankers, from a Scheduled bank/
valuation of assets with regard to Land for date of advertisement and Financial institution on their Letter Head and enclosed with the application. Please note that
1. Rs. •
godown mentioned in item 10 should not date of application. amount must be mentioned. If no specific amount is mentioned no marks will be awarded.)
2. Rs. • be included.
3. Rs. • TO WHOMSOEVER IT MAY CONCERN
10.5 Amount based on the certificate/letter from a As per Appendix-D
4. Rs. • Schedule Banks/Financial Institutions to extend Shri/Smt/Kum/M/s,....................................... is a customer of this bank for last….............… Years
loan as per Annexure D. In case no specific and he/she/they is/are enjoying the following facilities from our bank/institution :
Total Rs. •
amount is mentioned then it shall be taken as a)
Total amount in words nil and no marks will be awarded. b)
10.4 OTHER ASSETS/PROPERTY OF FAMILY as on the date of advertisement in the name of
Important Note : c)
applicant and members of ‘Family Unit’. Attach affidavit as per format given in
Appendix-C form member(s) of ‘Family Unit’. (Note: Gold should not be included) 1. Family Unit’ of a married applicant, shall consist of self, applicant's spouse and unmarried During the above period, the dealings of Shri/Smt/Kum/M/s ………………………..with the bank
son(s)/daughter(s) and ‘Family Unit’ of a unmarried Applicant, shall consist of self, applicant's and his/her/their conduct has been satisfactory. In case, RGGLV is allotted to him/her/them, we will
Value on the date of advertisement as certified by the Government Approved Valuer. The parents and applicant's unmarried brother(s)/sister(s) for the purpose of this entire application. be willing to extend a loan of Rs………… (In words ............) towards financing the same.
valuation of assets with regard to Land for godown mentioned in item 10 should not be
2. Applicant should provide only that information in the application against various items, for
included. Signature
which applicant is in possession of supporting documents in original as on the date of submission
Sl. Details of the Name of holder Relation with Value as per Government of application. Failure to present these documents in original at the time of verification can Name and Designation
No. Property etc the applicant approved valuer result in cancellation of selection. Office seal
1. Rs. • 3. Incase applicant requires extra space for providing details on any point, the details can be Date
2. Rs. • provided by adding extra rows or by adding extra sheets. However, details should be given in STANDARD RESIDENCE CERTIFICATE
3. Rs. • the same format as mentioned in that particular point.
(To given by the selected candidate at the time of Verification)
Total Rs. • Check list for Applicants
This is to certify that Shri/Smt/Kum ...................................................................................... son/
Total amount in words Sl. Particulars to be checked Check Box daughter/wife of ......................................................................... is a resident of ( name of town/
10.5 Details of the loan which can be obtained from Schedule Banks/Financial Institutions based No. village) .................................... District ..................................... State ............................ for
on Bankers/Financial Institution certificate to extend loan as per Annexure-D. If no specific 1 DD attached - verify amount, drawn in favour of ........................ years.
amount is mentioned then no marks will be awarded. concerned company and payable at
This certificate is issued for the purpose of applying for Rajiv Gandhi Gramin LPG
Name and address of the Date of Certificate Amount of Loan 2. Photograph pasted and signature across photograph Vitarak Yojana at ................................... .
Bank/Financial institution 3. Eligibility certificate for the category attached as applicable
D D - M M - Y Y 4. Notorised Affidavit as per Appendix - A as applicable attached (............................................................)
DECLARATION BY THE APPLICANT 5. Notorised Affidavit as per Appendix - B as applicable
I am aware that evaluation of candidates will be done based on the information given in the 6. Notorised Affidavit as per Appendix - C Date .................................. Signature of
application above. On verification by the Oil Company if it is found that the information given 7. Certificate as per Appendix - D as applicable Dy. Tehsildar/Tehsildar
by me is incorrect/false/misrepresented then my candidature will stand cancelled and I will Place ................................ Dy. Mamlatdar/Mamlatdar
8. Declaration by Applicant at the end is duly signed with name, (Seal of Office)
be declared ineligible for RGGLV. I also confirm that I am in possession of the supporting date and place
documents in original in respect of the information given by me in this application and if STANDARD FORMAT FOR SC/ST CATEGORY CERTIFICATE
9. All pages of application are numbered and signed
selected, failure to present these documents in original will result in cancellation of selection
due to submission of false/unsupported information in this application. 10. The Application is complete in all respect Note: A candidate who claims to belong to one of the Scheduled Castes / Scheduled Tribes should
submit in support of his/her claim, a certificate in original, with a copy thereof in the form given
I am fully aware that after selection if I am unable to provide LPG Godown duly approved by
below, issued at any time by a competent authority # notified by the Government of India, of the
the Office of Chief Controller of Explosives (PESO) and Showroom as per the Oil Company’s Appendix - A district in which his parents (or surviving parents) ordinarily reside who has been designated by the
standard layout, then the offer of RGGLV made to me will automatically stand cancelled. (NOTARISED AFFIDAVIT) State Government concerned as competent to issue such a certificate. If both his parents are dead,
I am fully aware that I will not be appointed as RGGLV if I am employed. I shall have to resign (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE) the officer signing the certificate should be of the District in which the candidate himself ordinarily
from the service and produce proof of acceptance of my resignation from my employer before I,............................................Son/Daughter/wife of ................................................. Age resides otherwise than for the purpose of his own education. In case of any doubt about the
issuance of Letter of Appointment. .................................. years residing at ................................ do hereby solemnly affirm and genuineness of the certificate, the same may be got verified through the concerned District Magistrate
I am aware that if married, my spouse will be co-owner of RGGLV with me. say as under : / Deputy Commissioner.
That, if selected, I undertake that I will deposit an interest free Security as per the policy of the 1. That I am an Indian Citizen and resident of (Name of Village), (Gram Panchayat), (District) in The form of the certificate to be produced by Scheduled Castes / Scheduled Tribes candidates.
Corporation. the State of ........................................
2. That my date of birth is d d / m m / y y y y (in words___________________) This is to certify that Shri/Smt./Kum*............................. son/daughter* of .......................... of village/
I have read the terms and conditions applicable for the RGGLV mentioned in the advertisement town *.............................. in District/Division* ....................... of the State/Union/ Territory* of
and confirm that I fulfil the eligibility criteria for the RGGLV I have applied for in this application. .......................... belongs to the ..................... Caste/Tribes and his/her religion is .................................
3. That I have passed Std X or equivalent examination in the year y y y y
I, .................................................................................. daughter of/son of/wife of Shri which is recognised as a Scheduled Castes/Scheduled Tribes under the Scheduled Castes/
and
................................................................ hereby confirm that the information given above is That I have passed Senior Secondary i.e.(10+2) CBSE or y y y y Scheduled Tribes lists (modification) order 1956* read with the Bombay Re-organisation Act, 1960
true and correct. Any wrong information/misrepresentation/ suppression of facts will make equivalent examination in the year* and the Punjab Reorganisation Act 1956*.
me ineligible for this RGGLV. and The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956*
Place : ........................................ Signature of applicant .................................... That I have passed Graduation examination in the year* y y y y
The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1956*
Date : d d - m m - y y y y Name of applicant ....................................... 4. That I am unmarried. That neither I, nor my Father, Mother, unmarried brother(s), unmarried
(In block letters) sister(s) have dealership/distributorship or hold Letter of Intent for Retail Outlet or SKO-LDO The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962*
List of Enclosures : dealership or LPG distributorship or RGGLV of any Oil Company. The Constitution (Pondicherry) Scheduled Castes Order, 1964*
1. Attested copy of Eligibility Certificate for the category applied. OR The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967*
2. Demand Draft No. ................................ dated ...................................... 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 The Constitution (Nagaland) Scheduled Tribes Order, 1970*
3. Affidavit in original as per the format in Appendix A
for Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company : Place : ............................. Signature : ....................................
4. Affidavit in original as per the format in Appendix B
OR Date : .............................. Designation : ................................. (with seal of office)
5. Affidavit in original as per the format in Appendix C
That I am widow/widower. That neither I nor my unmarried son(s)/unmarried daughter(s)
6. Letter from Bank/Financial Institution in original as per format in Appendix-D State/Union Territory*
(whose custody is given to me) have dealership/distributorship or hold letter of Intent for
Total number of pages of the application including attachments Retail Outlet or SKO-LDO dealership or LPG distributorship or RGGLV of any Oil Company : * Please delete the words which are not applicable.
General Instructions to the candidates applying for RGGLV OR (Note : The terms “Ordinarily reside(s)” used here will have the same meaning as in Section-20 of
That I am divorcee. That neither I nor my unmarried son(s)/unmarried daughter(s) have the Representation of the People Act, 1950.)
Item Instructions Supporting Documents to dealership/ distributorship or hold letter of Intent for Retail Outlet or SKO-LDO dealership or
# Officers competent to issue Caste/Tribe certificates.
No. be provide by applicant at LPG distributorship or RGGLV of any Oil Company:
the time of verification 5. That I am of sound mental health. i. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional
1. Write the name of the location for which 6. That I have never been convicted nor charges have ever been framed against me by any Deputy Commissioner/Deputy Collector, 1st Class Stipendiary Magistrate/City Magistrate ***
application is made as per advertisement Court of Law for any criminal offences involving moral turpitude and/or economic offences Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant
2. Write the name of the Gram Panchayat of the As per advertisement (other than freedom struggle). Commissioner.
location for which application is made as per 7. That I hereby confirm that I was never a signatory to dealership/distributorship agreement of *** (Not below the rank of 1st Class Stipendiary Magistrate)
advertisement any Oil Company, which was terminated for proven malpractices and/or for violations of
provisions of the Marketing Discipline Guidelines. ii. Chief Presidency Magistrate/Additional Chief Presidency Magistrate, Presidency Magistrate.
3. Write the name of the district of the location for
which application is made as per advertisement 8. That if any information/declaration given by me in my application or in any document submitted iii. Revenue Officers not below the rank of Tehsildar.
4. Write the name of the State of the location for by me in support of application for the award of the RGGLV or in this affidavit shall be found iv. Sub-divisional officer of the area where the candidate and/or his family normally resides.
to be untrue or incorrect or false, the Indian Oil Corporation*/Bharat Petroleum Corporation*/
which application is made as per advertisement v. Administrative/Secretary to Administrator/Development Officer (Lakshadweep).
Hindustan Petroleum Corporation* would be within its rights to withdraw the letter of intent/
5. Write the name of the category of the location Certificate issued by the terminate the distributorship (if already appointed) and that I would have no claim, whatsoever,
as per the advertisement competent authority. Caste STANDARD FORMAT FOR PH CATEGORY CERTIFICATE
against the Corporation for such withdrawal/termination.
validity Certificate as applicable NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE
* Strike off whatever is not applicable.
6. Write the date and name of the news paper I hereby verify that what has been stated above is true and correct to the best of my knowledge Certificate No.
in which advertisement has appeared for the and nothing material has been concealed therefrom. Date
location mentioned in item 1.
Solemnly affirmed and declared before me CERTIFICATE FOR THE PERSONS WITH DISABILITIES
7. For Item No. 7.1 to 7.8 Notorised Affidavit-A to be
submitted. A residency certificate This ...................................... day of .......................................
This is to certify that Shri/Smt./Kum....................... wife/daughter/son of Shri ............................ Age
in the standard format from the ......................... old male/female, Registration No. ....................................... is a case of physically
competent authority Signature and seal of Signature of person making affidavit disabled/visual disabled/speech & hearing disabled and has .................................... %
8. Education - Information in chronological order Original certificate for each Magistrate/Judge/Notary Public (Name in block letters) (.....................................) permanent (physical impairment/visual impairment/speech & hearing
qualification Appendix - B impairment) in relation to his/her ...................................................................................
9. Details of land for construction of godown & showroom : In case applicant does not (NOTARISED AFFIDAVIT) Note:
provide any information, then it will be deemed that applicant does not have required (TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAM PAPER OF REQUIRED VALUE)
land and hence applicant will be ineligible for RGGLV 1. This condition is progressive/non-progressive/likely to improve/not likely to improve*.
DECLARATION OF ANNUAL INCOME
Please provide the details of Land as per Registered Sale Deed/Gift Deed/ 2. Re-assessment is not recommended/is recommended after a period of ........................... months/
the format Mutation and government record I,....................................................son/daughter/wife of .................................................. Age years.
etc. The date of the documents ........................... years residing at .....................................................do hereby solemnly affirm and
*Strike out which is not applicable.
have to be on or before the date declare details of my gross annual income as under :
of application. Consent from the Please give details of income of the last financial year (20--/--) Sd/- Sd/- Sd/-
family member in form of Gross income should be indicated and not net income
Notorized Affidavit (Appendix-C) (DOCTOR) (DOCTOR) (DOCTOR)
is required. If required, certificate Details of Gross Annual Income in Rupees Seal Seal Seal
from the concerned authority Relationship Gross Property Interest/ Business Professional Income Income Total Signature/Thumb impression of the patient
stating that the land is free from Salary (net Dividend (Net profit) Income from from other (I+II+
live overhead power transmission Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal)
income) (Net of Agriculture sources e.g. III+IV+
or telephone lines expenses) (Net of pension, etc. V+VI+ Recent Attested PhotographShowing the disability affixed here.
10. Financial Capability expenses) VII)
10.1 Gross Annual Income of the "Family Unit" for Notorised Affidavit as per STANDARD FORMAT FOR PARAMILITARY/POLICE/GOVERNMENT
I II III IV V VI VII VIII
the last financial year. The income should Appendix-B and all the PERSONNEL CATEGORY
1. Self
include income from all sources such as documents based on which the Certificate is to be given by Head of the Office or an Officer not below the rank of Under Secretary
salary, property, interest, dividend, business/ income is shown in the Affidavit 2. Spouse
to the Government on Official Letter-Head of the Organization/Government Office issuing the
profession/vocation, agriculture and other 3. Unmarried Certificate.
sources, if any. son/
daughter NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE
If the applicant is an Income Tax Assessee, the
details of income as shown in the Annual Income In case Applicant is unmarried, income of mother, father, unmarried brother(s)/unmarried sister(s) can be Reference No.
Declaration should conform to those indicated given in case notarised affidavit as per Appendix-C is attached Date
in the income tax return for the relevant Father
financial year. Eligibility Certificate for Paramilitary/Policy/Government Personnel Category
Mother I. This is to certify that Mr/Ms (name of applicant) ........................................ was working in our
If, however, the applicant is not an Income
Tax Assessee then the details are required to Unmarried organisation ................... and has been disabled on (date) ..................... while performing
be supported with other relevant document(s) sister(s)/ duties at (place) .........................
some of which are mentioned below for brotehr(s)
OR
illustration purpose only.
I hereby declare that I am an Income Tax payer and I am attaching here with the copy of my II. This is to certify that Mr/Mrs ....................................... who was working in this office as
a) Gross Salary : A certificate from the Income Tax Return for the above Financial Year*
employer(s) indicating the total emoluments paid .............. had passed away on (date) .................. while on duty at (Place) ............
b) Income from property : Rent as declared I hereby declare that I am not an Income Tax payer* Mr/Ms (name of applicant) ....................... (relationship .....................) was dependent on Mr/
and assessed for the purpose of tax. *Strike off whichever is not applicable Ms .............................. as per our records.
c) Interest on Bank Deposits : Letter issued Solemnly affirmed and declared before me
by competent authority from Bank(s) showing
This ....................... day of ..................... Attested Signatures of applicant
the actual amount paid/credited as interest.
d) Income from business/profession/vocation/ Signature and Seal of Signature of Deponent Place : ................................ Signature
shares and other investment/other sources : Magistrate/Judge/Notary public (Name in block letters)
Certificate from Chartered Account in support Date : ................................ Name :
1. It is important to give precise information under each head i.e. I to VII, if income under any
of the income indicated under each of these Designation :
heads will be required. The applicant may also head is NIL, then it should be indicated specifically as NIL and not left blank.
Office Seal :
be required to produce any other documentary 2. If the applicant is payee of Income Tax, a copy of Income Tax Return should be attached.
