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NOTIFICATION FOR APPOINTMENT UNDER THE RAJIV GANDHI GRAMIN LPG VITARAK FOR ORISSA

1. INDIAN OIL CORPORATION LTD (IOCL), BHARAT PETROLEUM CORPORATION LTD (BPCL) and HINDUSTAN PETROLEUM CORPORATION LTD (HPCL) propose to appoint RAJIV GANDHI GRAMIN LPG VITARAK (RGGLV) under various categories at locations specified below from amongst the candidates belonging to different categories mentioned herein in the State of Orissa: Name of Block Anugul Banarpal Remuna Baleshwar Sadar Jaleswar Jaleswar Bahanaga Barapali Bargarh Bargarh Harabhanga Baudh Sadar Bant Chandbali Bhadrak Tihidi Agalpur Cuttack Sadar Salepur Hindol Dhenkanal Sadar Riamal Gumma Parlakhemundi Raygad Chhatrapur Ganjam Rangeilunda Hinjili Biridi District Anugul Anugul Baleswar Baleswar Baleswar Baleswar Baleswar Bargarh Bargarh Bargarh Baudh Baudh Bhadrak Bhadrak Bhadrak Bhadrak Bolangir Cuttack Cuttack Dhenkanal Dhenkanal Debagarh Gajapati Gajapati Gajapati Ganjam Ganjam Ganjam Ganjam Jagatsinghpur Category O CC SC SC O CC SC ST O CC O SC O CC O SC O CC O SC O CC O SC O CC SC SC O CC O O ST CC O ST O CC O SC O CC O ST 142 Patana Saharapada Hatadihi Koraput Semiliguda Kalimela Podia Kusumi Badsahi Saraskona Sukruli Jharigam Nandahandi Raighar Bhapur Odagaon Ranpur Khariar Khariar Brahmagiri Astaranga Kalyanasingpur Muniguda Dhankauda Jamanikira Dunguripalli Sonepur Baragaon Manesar Kendujhar Kendujhar Kendujhar Koraput Koraput Malkangiri Malkangiri Mayurbhanj Mayurbhanj Mayurbhanj Mayurbhanj Nabarangapur Nabarangapur Nabarangapur Nayagarh Nayagarh Nayagarh Nuapada Nuapada Puri Puri Rayagada Rayagada Sambalpur Sambalpur Sonepur Sonepur Sundargarh Sambalpur ST CC O ST ST CC ST ST ST CC ST ST O CC O SC O CC O SC O CC O ST O CC O ST O O O CC ST SC O CC O ST O CC 3 143 144 145 146 147 148 149 HPC HPC HPC HPC HPC HPC HPC HPC 134 135 136 137 Garadpur Rajkanika Kendujhar Sadar Kendrapada Kendrapada Kendujhar 138 139 140 141 HPC HPC HPC HPC HPC HPC HPC HPC Sl. Oil Name of RGGLV Location No. Company (Town/Village(s)) 1 IOC Pokatunga, Bantala, Talagarh, Sankhapur 2 IOC Balaramprasad (Part), Kandasar (Part), Kulad (Part) 3 IOC Tundara, Srijang, Karanjia, Shergada 4 IOC Gudu, Chandipur, Hidigan, Ranasahi 5 IOC Gabarghata, Rayramchandrapur Rajpur, Kalama 6 IOC Debkumar, Nampo, Jharpimpal 7 IOC Bishnupur, Kharasahapur, Abhana 8 IOC Kumbhari, Patkulunda, Bandhapalli, Tulandi 9 IOC Chakrakend, Katapalli, Khaliapalli Bardol 10 IOC Dhanger, Khandata, Barahaguda, Adgaon 11 IOC Sarasara, Harabhanga, Kusanga, Bandhapathar 12 IOC Bahira, Laxmiprasad, Baunsuni, Sangrampur 13 IOC Purusandha, Mahantipada, Charigan, Chakarapadhi 14 IOC Karanapali, Nuaganichapur, Karanapokhari, Charadia 15 IOC Erei, Olang, Randia, Bahudarada 16 IOC Dolasahi, Maharampur, Harisinghpur, Barsar 17 IOC Agalpur, Bharasuja, Duduka, Salebhata 18 IOC Gatiroutpatana, Arad, Praharajpur, Urali 19 IOC Paschimakachha, Gopinathpur, Biswanathpur, Mutarifa 20 IOC Dudurokot, Kukuta, Ranjagola 21 IOC Talbarkota, Bhapur, Chaulia 22 IOC Khilei, Kundheigola, Karlaga, Palasama 23 IOC Gumma, Seranga, Jhami, Jeeba 24 IOC Gurandi, Kharasanda, Upaloda, Bhuskudi 25 IOC Raygad, Narayanpur, Burujang, Gandahati 26 IOC Badamadhapur, Agastinuagan, Sriramachandrapur 27 IOC Aliabada, Humma, Palurgada 28 IOC Korapalli, Kamalapur, Luhajhara, Gounju 29 IOC Durbandha, Sikiri, Burupada 30 IOC Arana, Gopinathpur, Adhangagarha, Basandara 31 IOC Jotta, Rasalpur, Jasabantapur, Kendal 32 IOC Teramanpur, Gorada Pandua, Talapada 33 IOC Paradeepgarh, Biswali, Bhutumundai 34 IOC Charinangal, Panasuda, Kalashree 35 IOC Marjidapur, Kabatabandha, Neulphur 36 IOC Kiajhar (Tomka Forest Block), Rachhipur, Chitri 37 IOC Angalo, Bari, Nathapur, Bainsira 38 IOC Kolabira, Raghunathpalli, Samasingha, Parmanpur 39 IOC Brundabahal, Mahaling, Chapria, Sanchergaon 40 IOC Brahmunigaon, Gadapur, Kiramaha, Katingia 41 IOC Sarangagada, Nuagan, Mahasinghi, Kanjamendi 42 IOC Garadpur, Pakhada, Kalabuda, Tendakuda 43 IOC Namatara, Barunadia, Ganja, Charapada 44 IOC Raisuan, Gobardhan, Silisuan, Nelung 45 IOC Baunsuli, Khireitangiri, Rajanagar, Bhulada 46 IOC Udayapur, Begana, Goras, Tando 47 IOC Balibarei, Soso, Bidyadharapur, Sadha 48 IOC Kerenga, Umuri, Semala 49 IOC Dusura, Aligan, Swain, Kunduli 50 IOC Kalimela, Chitongpalli, Tamanpally, Salmanikonda 51 IOC Motu, Podia, Kunanpalli, Lachhipeta 52 IOC Jaypur, Kusumi, Dhangdimuta, Aharbandha 53 IOC Badasahi, Deulia, Haripur, Uthaninuagaon 54 IOC Umadeipur, Jharpokharia, Sirsa, Nuhamaliasahar 55 IOC Teranti, Pandarsil, Jamuti, Kasia 56 IOC Dongriguda, Purla, Jharigam, Ratakhandiguda 57 IOC Maliguda, Padhalguda, Sindhiguda 58 IOC Raighar, Sonpur, Mundibeda 59 IOC Baigunia, Karabar, Bhapur, Fategarh 60 IOC Sarankul, Godipada, Odagaon 61 IOC Goplapur, Damsahi, Khatia 62 IOC Duajhar, Kendupati, Tukula 63 IOC Bhulia Sikuan, Bargaon, Chanabeda, Badi 64 IOC Alarpur, Dimirisena, Kapileswarpur, Rebena Nuagaon 65 IOC Naiguan, Astaranga, Nagar, Alasahi 66 IOC Kalyanasingpur, Sikarpai, Bijinagar, Majhiguda 67 IOC Amalabhata, Tikarpada, Ambadala, Gobardhan 68 IOC A.Katapalli (Sikirdi), Chipilima, Kalamati, Baijamunda 69 IOC Jamanikira, Kulundi, Tikilipada, Mundenpalli 70 IOC Rampur, Badkarle, Gajabandh 71 IOC Mallikmunda, Khameswaripali, Kharjhura, Baidyanath 72 IOC Pamra, Itma, Sahajbahal, Bargaon 73 IOC Manesar, Rasanpur, Parmanpur, Themera 74 IOC Turkela 75 BPC Agrahat, Sankarpur, Bandalo 76 BPC Alipingal, Rasalpur, Jasabantapur, Odiso 77 BPC Amarada, Kanpur, Rasagovindpur 78 BPC Arakhapur, Chingudighai, Sikula 79 BPC Argal, Govindpur, Madhuban 80 BPC Badagada, Sidhapur 81 BPC Baulabandha, Sananairi 82 BPC Bhagamunda, Sagadapata, Billa 83 BPC Birapratappur, Biranarasinghpur, Janakadeipur, Balabhadrapur Uttarhana 84 BPC Dengadi, Addapada, Khallingi Sl. Oil Name of RGGLV Location No. Company (Town/Village(s)) 85 BPC Dharadharpur, Jaganathpur, Purunaodapada 86 BPC Gallery, Harigada, Badangi 87 BPC Golabaisasan, Mundaamba, Mota, Naranagarh 88 BPC Jadida, Majhigadia, Mahulpankha 89 BPC Jagannathprasad, Daruthenga, Chandaka Jogisahi 90 BPC Jarasingha, Turanga 91 BPC Jari, Oleichandanapur, Tina 92 BPC Kanika pada, Khana nagar, Dhani pur 93 BPC Kanpur, Orabarasingh 94 BPC Kantiokateni, Kantioputasahi 95 BPC Keranga, Thakurpada, Taratua 96 BPC Khalisahi, Sikharapur, Gunthuni No-1 97 BPC Khaman, Dhaneswar, Janha 98 BPC Kharagprasad , Mangalpur, Kamalanga 99 BPC Khukundia, Singipur, Gahangu 100 BPC Mahammadpur, Manijanga, Babujanga 101 BPC Nagapur, Erabanga, Kusupur 102 BPC Naharana, Baradia, Dasabatia 103 BPC Oranda, Gobara, Bali 104 BPC Paliabindha, Saya 105 BPC Panchagan, Jemadeipur, Nizigarh 106 BPC Ramagarh, Kanheipur, Karanji 107 BPC Saranga, Barihapur 108 BPC Sibtala, Kudasingha, Nuapada, Chikalbahal 109 BPC Talapada, Bhimpur 110 BPC Kapsila, Tandigaon, Gudbhela, Nuapara 111 BPC Chandrapur, Baruguda, Bondaguri, Kutama 112 HPC Kumanda, Jarasinga, Sakasinga 113 HPC Matiali, Garadihi, Naranpur, Bhaunriabad 114 HPC Kumarpur, Kismatkrushnapur 115 HPC Mohantipada, Tillo, Anijo 116 HPC Tusura, Samara, Chantipadar 117 118 119 120 121 122 123 124 125 126 127 128 129 Kujang Badachana Dharmasala Dangadi Bari Kolabira Golamunda Daringibadi K.Nuagan Jagatsinghpur Jajpur Jajpur Jajpur Jajpur Jharsuguda Kalahandi Kandhamal Kandhamal 130 131 132 133 HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC HPC Ekadal, Kanjiapada, Champeswar, Baselihata Brahmankhanda, Lendurabhagabanpur, Khandagan Bindanima, Achalkota, Purunatigiria Surapratappur, Odisha Rasol, Karanda Biranchipur, Ballipadar, Adipur Jayantipur, Patrapur, Surangi, Jaradagada Gobindapur, Gothagam, Pitala Baradia, Tentulibelari, Dasabatia, Dhanuhar Belari Malikapur, Kasapa Brahmabarada, Kalan Paramanandapur, Kamthana, Medinipur Tumudibandha, Mundigada, Kurtamgada Damar pur, Srirampur, Palapatna, Balipatna Bhakarsahi, Abhaya Mukhi, Bhapur, Nariso Majhihara, Garedipanchan, Biswanathpur Rajas, Makundadaspur, Alisisason Kantabad, Jujhagada, Andharua, Nanapada, Damanbhuin, Dia Kaipadar, Bajapur, Palatotapada Hordali, Kanagam, Jhilimili Gundala, Kundura, Limma Chitrada, Khuruntia, Anua, Muruda Chakradharprasada, Madhapur, Patharachakada Sikharpur, Dimisar, Nandhighor Chandanpur, Pratapramachandrapur, Pratap Purusottampur Kumudabali, Jagadalpur, Bhairagoda Ramnaguda, Parikhati, Rugudubai, Kondajam Kolnara, Elegalupadu, Dondili Jimidipeta, Bahinipati Kerada, Gajigam Balikuda, Balisahi, Kalio, Ambasala Indupur Kolnara Rayagada Balikuda Kendrapada Rayagada Rayagada Jagatsinghpur Kendrapada O ST O O 8. SELECTION PROCESS AND EVALUATION CRITERIA All the applicants satisfying the eligibility criteria will be evaluated out of total 100 marks based on information given in the application. The evaluation will be done on the following parameters: Sl. No 1. 2. 3. Parameter Financial Capability Income Educational Qualification Max marks 50 10 40 Muniguda Ramnaguda Rayagada Rayagada O CC Odagaon Puri Nayagarh Puri O SC 112 149 Balipatna Bhubaneswar Tangi Khorda Boriguma Kundra Muruda Bhapur Khordha Khordha Khordha Khordha Koraput Koraput Mayurbhanj Nayagarh O ST O CC ST ST O CC 75 111 Balipatna Khordha CC Balipatna Khordha O 7. Pattamundai Kendrapada SC Tumudibandha Kandhamal ST Dasarathpur Rasulpur Bhawanipatna Jajpur Jajpur Kalahandi O O CC 5. 6. Name of Block District Category SC ST ST CC O O SC CC ST ST ST CC SC SC O CC O O ST CC O SC O CC O ST O O CC O SC O CC O ST O CC O SC O CC O 4 SPECIFIC ELIGIBILITY CRITERIA FOR DIFFERENT CATEGORIES : a. Raghunathpur Jagatsinghpur Bhanjanagar Khordha Kaptipada Bhubaneswar Ganjam Khordha Mayurbhanj Khordha b. Open Category (O) Scheduled Caste/ Scheduled Tribe Category (SC/ST): Candidate fulfilling common eligibility criteria can apply under `Open' category. The candidates belonging to castes/tribes recognised as Scheduled Castes/ Scheduled Tribes (SC/ST) under the Constitution of India will be eligible. The candidates will be required to submit along with application a certificate issued by the competent authority notified by the Government of India certifying that the candidate belongs to Scheduled Caste /Scheduled Tribe. c. Combined Category (CC) Applicants belonging to any of the following categories can apply for RGGLV under `Combined Category'. i) Defence Personnel Category (DP): Defence Personnel means personnel of armed forces (viz. Army, Navy, Airforce) and will cover widows/dependents of those who died in war, war disabled/disabled on duty, widows/ dependent of those members of Armed Forces who died in harness due to attributable causes and disabled in peace due to attributable causes. Candidate applying under this Category should produce Eligibility Certificate issued from Directorate General of Resettlement (DGR), Ministry of Defence, and Government of India sponsoring the candidate for the RGGLV for which he/she has applied. Certificate of eligibility issued for one RGGLV is not valid for another RGGLV and therefore a candidate can be considered to be eligible only if he/she has been sponsored for the particular location with reference to current advertisement ii) Paramilitary/Police/Government Personnel Category (PMP): The personnel of Paramilitary/Police including persons having served in BSF, CRPF, CISF, ITBP, Railway Protection Force, Special Reserved Police, Special Armed Police, Coast Guards, Assam Rifles etc. as designated by Central Government and Police Forces of the States, Customs and Central Excise Department, Narcotics Control Bureau, Enforcement Directorate, Economic Intelligence Bureau, Directorate General of Anti-Evasion and Directorate of Revenue Intelligence and those serving in different Departments of Central/State Governments who are incapacitated or disabled while performing their duties will be eligible under this category. In case of death, while performing duties, their widows/ dependants will also be eligible under this category. Candidate applying under this category should attach a copy of relevant certificate from the concerned Organisation/Govt Department signed by the Head of the Office or an Officer not below the rank of Under Secretary to the Government. iii) Physically Handicapped Category (PH) Candidates would be considered eligible under this category in case the candidates are orthopaedically handicapped to the extent of minimum of 40% permanent (partial) disability of either upper or lower limbs; or 50% permanent (partial) disability of both upper and lower limbs together. For this purpose, the standards contained in the `Manual for Orthopaedic Surgeon in evaluating Permanent Physically Impairment' brought out by the American Academy of Orthopaedic Surgeons, USA and published on its behalf by the Artificial Limbs Manufacturing Corporation of India, G.T. Road, Kanpur, shall apply. Deaf, Dumb and Blind persons with minimum degree of 40% disability will also be eligible to apply for all RGGLVs/dealership under this category. However, totally blind persons will not be eligible. Candidate applying under this category should produce a certificate (as per the standard format given the application format) issued by a Medical Board duly constituted by the Central / State Government as per the Gazette of India Extraordinary New Delhi, No 154 dated June 13, 2001 on Guidelines for evaluation of various disabilities and procedure for certification. iv) Outstanding Sports Persons Category (OSP) The following persons will be eligible : (i) Arjuna/Khel Ratna Awardees. (ii) Winners of Medals at Olympics/Asian/Commonwealth Games and Recognised World Champions/World Championships. (iii) National Champions (First position) under the Recognised National Championships. (iv) National Adventure Awardees. Candidate applying under this category should produce a certificate from the Recognised 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 India. Application can be made on plain paper (preferably typed) as per the prescribed format given in this advertisement. APPLICATION PROCESSING FEE: Application to be submitted along with non-refundable fee of Rs 1000 (Rupees One thousand only) and in case of SC/ST candidates (SC/ST certificate to be attached) Rs 500/- (Rupees five hundred). APPLICATION (AS PER FORMAT GIVEN IN THIS ADVERTISEMENT) for RGGLV along with enclosures complete in all respect and Non-refundable fee by a Demand Draft/Pay Order drawn on any Scheduled Bank must be submitted so as to reach the office address mentioned below before 4.30 pm on 31.03.2011 Payable at Office Address for submitting application along with enclosures and application processing fee

Banarpal Anugul Binjharpur Jajpur Dasarathpur Jajpur Khordha Khordha Kamakhyanagar Dhenkanal Khordha Khordha Khandapada Nayagarh Korei Jajpur Odapada Dhenkanal Aska Ganjam Nischintakoili Cuttack Gop Puri Balikuda Jagatsinghpur Athagad Cuttack Tihidi Bhadrak Tigria Cuttack Tangi-Choudwar Cuttack Parajang Dhenkanal Balangir Bolangir Baleswar Tentulikhunti (Gudvella) Chandrapur Banarpal Nilagiri Basudevpur Bant Tentulikhunti (Gudvella) Narasinghpur Nischintakoili Tigiria Bhuban Hindol Buguda Patrapur Shergada Balikuda Baleswar Bolangir Rayagada Anugul Baleswar Bhadrak Bhadrak Bolangir Cuttack Cuttack Cuttack Dhenkanal Dhenkanal Ganjam Ganjam Ganjam Ganjam Jagatsinghpur

Pratappur, Balakrishnapur, Ranajhali Purushottampur

Jagatsinghapur (P) Jagatsinghpur Kujang Jagatsinghpur

Advertised locations Demand Draft/Pay Sl. No Order drawn on any Scheduled Bank From To Drawn in favour of 01 74

IndianOil Corporation Bhubaneswar Area Manager, Indane Area Office, Limited (MD) IndianOil Corporation Limited (MD), Alok Bharti (3rd Floor), Bhubaneswar751007, Ph : 0674-2542241/2542896 Bharat Petroleum Corporation Limited Bhubaneswar Territory Manager (LPG), Bharat Petroleum Corporation Limited, LPG Bottling Plant & Territory Office, Plot no.33, Industrial Estate, PO : PN College, Khurda, ORISSA ­ 752057 Ph : 06755-223324/25

Hindustan Petroleum Bhubaneswar Sr.Regional Manager, Hindustan Corporation Limited Petroleum Corporation Limited, Bhubaneswar LPG Regional Office, Jatni LPG Bottling Plant, PO : Jatni Dist : Khurda, Pin-752050 Ph : 0674-2492912

Abbreviations used in ``Category'' column are : `O' Stands for Open category, `SC/ST' stands for Scheduled Caste/ Scheduled Tribe category and `CC' Stands for Combined Category 2 Only Individuals are eligible to apply. However, on appointment all RGGLVs will be jointly in the names of applicant and his/her spouse (i.e wife/husband will be co-owner of RGGLVs). In case, the applicant is unmarried/divorcee/widow/widower, an undertaking will be required to be given that after marriage/re-marriage, spouse will be made co-owner. There will be no educational qualification requirement for spouse. COMMON ELIGIBILITY CRITERIA FOR ALL CATEGORIES : Applicant applying for RGGLV should (a) be an Indian citizen. (b) be a resident of the town/village(s) of the advertised RGGLV location. (c) have passed minimum Xth Standard examination or equivalent from recognised Board. (d) be not less than 21 years and not more than 45 years in age as on the date of application. (e) fulfill Multiple Dealership/Distributorship norm. Multiple Dealership/Distributorship norms means that the applicant or any other member of `family unit' should not hold a dealership/distributorship/RGGLV or Letter of Intent (LOI) for a dealership/distributorship/RGGLV of a PSU Oil Company i.e only one Retail Outlet/SKO-LDO dealership/LPG distributorship/RGGLV of PSU Oil Company will be allowed to a `Family Unit'. `Family Unit' in case of married person/ applicant, shall consist of individual concerned, his/ her Spouse and their unmarried son(s)/daughter(s). In case of unmarried person/ applicant, `Family Unit' shall consist of individual concerned, his/her parents and his/her unmarried brother(s) and unmarried sister(s). In case of divorcee, `Family Unit' shall consist of individual concerned, unmarried son(s)/unmarried daughter(s) whose custody is given to him/her. In case of widow/widower, `Family Unit' shall consist of individual concerned, unmarried son(s)/ unmarried daughter(s). (f) have minimum total amount of Rs 2 lakhs put together from Saving accounts in Bank (as on date of application), free and un-encumbered fixed deposits in scheduled banks, Kisan Vikas Patra, NSC, bonds, any other investment, etc in the name of self or family members of the `Family Unit' as defined above. (In case of RGGLV locations reserved under `SC/ST' category, applicants with less than Rs 2 lakhs are also eligible to apply). For evaluation purpose, marks will be awarded to applicants of all categories based on the amount mentioned in the application. (g) own a suitable land (plot) of minimum 20 metre X 24 metre in dimension at the advertised RGGLV location for construction of LPG cylinder Storage Godown. Own means having ownership title of the property in the name of applicant/family member of the `Family Unit' as defined in multiple dealership/distributorship norm. In case of ownership/ co-ownership by family member, consent letter from the family member will be required. Land for construction of Godown will be considered suitable, if it is freely accessible through all weather motorable approach road (public road or private road of the applicant connecting to the public road) and should be plain, in one contiguous plot, free from live overhead power transmission or telephone lines. Pipelines / Canals / Drainage / Nallahs should not be passing through the plot. (h) be physically and mentally sound to be able to run the business (i) (j) neither have been convicted nor charges been framed by any Court of Law for any criminal offence involving moral turpitude/ economic offences. not be a signatory to distributorship/dealerships agreement, terminated on account of proven cases of malpractice/adulteration of any Oil Company. 9.

Selection for RGGLV will be done by draw of lot amongst all eligible applicants securing minimum qualifying marks. Minimum qualifying marks is 60% for RGGLVs reserved under SC/ST category and minimum 80% marks for all other category locations. Detailed guidelines including detailed criteria for evaluation and draw of lot is given in the Brochure, which can be collected personally from the address mentioned at para 7 above at a cost of Rs. 50/- to be paid through Demand Draft / Pay Order as per point 7 above. It is also available on the website of respective oil companies ­www.iocl.com; www.ebharatgas.com; www.bharatpetroleum.in and www.hindustanpetroleum.com BASIC INFRASTRUCTURE FACILITIES REQUIRED FOR OPERATION OF RGGLV ­ LPG Storage Godown and Showroom. RGGLV would require a storage Godown approved and licensed by Chief Controller of Explosives of Petroleum and Explosives Safety Organisation (PESO) for storage of LPG in cylinders. A showroom of the dimensions 2.6 m X 3 m is required to be constructed near the Godown or operated from an existing nearby shop. For construction of Godown, land should be of Minimum Dimensions 20 metre X 24 metre. It should be freely accessible through all weather motorable approach road (public road or private road of the applicant connecting to the public road) and should be plain, in one contiguous plot, free from live overhead power transmission or telephone lines. Canals / Drainage/Nallahs should not be passing through the plot RGGLV will not be required to deliver LPG cylinders at the residence of the customers. LPG cylinders will be given to the customers from the authorised licensed LPG Godown at the Retail Selling Price(RSP). 10. CORPUS FUND SCHEME - Financial Assistance to Candidates Selected for RGGLV Locations Reserved Under SC/ST Category. Candidate Selected for RGGLV locations reserved under SC/ST category will be provided a secured loan of Rs. One Lakh for construction of Godown/other facilities by the concerned Oil Company. This amount will be recovered on per refill basis at the rate of 20% of distributor's commission for 14.2 kg cylinders as per policy. For RGGLV locations reserved under SC/ST category, the concerned Oil Company will provide adequate working capital loan for operation of the RGGLV at an interest rate of 11% per annum on reducing balance. Both, the working capital loan as well as interest will be recovered in 100 equal monthly installments from 13th month of commissioning of the RGGLV. 11. SECURITY DEPOSIT The selected candidate before being issued the appointment letter shall have to deposit interest free refundable security deposit of Rs. 2 lakhs with the concerned Oil Company. The Concerned Oil Company will have the right to adjust any dues to it from this amount at the time of resignation/ termination. However, in case of termination of the RGGLV on account of proven malpractice, the said security deposit shall be forfeited. 12. PERSONAL SUPERVISION A person selected for RGGLV should personally manage it. He/she will not be eligible for taking up any other employment. If the selected person is already employed he/she will have

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Turkela Bolangir Tangi-Choudwar Cuttack Jagatsinghapur (P) Jagatsinghpur Rasagobindpur Mayurbhanj Purusottampur Ganjam Aul Kendrapada Sorada Ganjam Chilika Khordha Harichandanpur Kendujhar Puri Puri Sanakhemundi Ganjam

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to resign from the employment & produce the letter of acceptance of resignation by the employer before the issuance of Letter of Appointment by the Oil Company. 13. COMMISSIONING OF RGGLV Field verification will be carried out for the selected candidate and if information given in the application by the candidate is found to be correct, Letter of Intent will be issued. Selected candidate who has been given the `Letter of Intent' (LOI) would be required to fulfil the terms and conditions as contained therein, so as to commission the RGGLV within the stipulated time period. Before commissioning, Letter of Appointment will be given and RGGLV agreement shall be executed. The duration of the agreement will be initially for five years, renewable for every five years thereafter, subject to the satisfactory performance of the RGGLV. 14. GENERAL (a) The company reserves the right to cancel/withdraw/amend this advertisement or extend the due date at its sole discretion without assigning any reason. (b) Application for RGGLV can be submitted on a plain paper hand written neatly or typed as per format given in the advertisement. Applicant should number all pages of the application including affidavits attached therewith and sign on each page. All affidavits have to be submitted in original along with the application. (c) Only those documents that are sought in the Application format should be submitted along with the application. (d) Applications received after the cut-off date including postal delay, will not be considered. No correspondence will be entertained by respective Oil Company in such cases. (e) Except for locations advertised under `Open' category, the eligibility certificate for the respective categories viz ­ `SC/ST', and Combined Category (CC) consisting of Defence Personnel (DP), Paramilitary/Police/Government Personnel (PMP), Outstanding Sports Personnel (OSP), and Physically Handicapped (PH) has to be submitted. (f) If any statement made in the application or in the documents enclosed therewith or subsequently submitted in pursuance of the application by the candidate at any stage is found to be incorrect or false, the candidature and application is liable to be rejected without assigning any reason and in case the applicant has been appointed as a RGGLV, the same is liable to be terminated. In such cases the candidate/RGGLV shall have no claim whatsoever against the respective Oil Company.

10.3 FIXED DEPOSIT/NSC/SHARES/MF ETC. as on date of advertisement in the name of applicant and members of `Family Unit'. Attach affidavit as per format given in Appendix-C from member(s) of `Family Unit'. Sl. Type of No. Investment FD/NSC/ Shares/ MF etc 1. 2. 3. 4. Reference Name(s) Relation Initial Number of the with investment with date holder applicant Amount Value (Amount) as on the date of advertisement

10.4

Total Total amount in words

Rs. Rs. Rs. Rs. Rs.

· · · · ·

10.5

Other assets/Property( immovable) in the name of the member of the "Family Unit" as on the date of advertisement. Assets/Property in the name of joint account of the member(s) outside the "Family Unit" should not be mentioned. (Note: Gold should not be included). The valuation of assets with regard to Land for godown mentioned in item 9 should not be included. Amount based on the certificate/letter from a Schedule Banks/Financial Institutions to extend loan as per Annexure D. In case no specific amount is mentioned then it shall be taken as nil and no marks will be awarded.

Valuation certificate by Govt. Approved Valuer should give the Value of assets as prevailing on the date of advertisement. Date of Valuation Certificate should between date of advertisement and date of application. As per Appendix-D

10.4 OTHER ASSETS/PROPERTY OF FAMILY as on the date of advertisement in the name of applicant and members of `Family Unit'. Attach affidavit as per format given in Appendix-C from member(s) of `Family Unit'. (Note: Gold should not be included) Value on the date of advertisement as certified by the Government Approved Valuer. The valuation of assets with regard to Land for godown mentioned in item 9 should not be included. Sl. No. 1. 2. 3. Details of the Property Name of holder Relation with the applicant Value as per Government approved valuer Rs. · Rs. · Rs. · Rs. ·

Total Total amount in words

Important Note : 1. Family Unit' of a married applicant, shall consist of self, applicant's spouse and unmarried son(s)/daughter(s) and `Family Unit' of a unmarried Applicant, shall consist of self, applicant's parents and applicant's unmarried brother(s)/sister(s) for the purpose of this entire application. 2. Applicant should provide only that information in the application against various items, for which applicant is in possession of supporting documents in original as on the date of submission of application. Failure to present these documents in original at the time of verification can result in cancellation of selection. 3. Incase applicant requires extra space for providing details on any point, the details can be provided by adding extra rows or by adding extra sheets. However, details should be given in the same format as mentioned in that particular point. Check list for Applicants Sl. No. 1 2. 3. 4. 5. 6. 7. 8. 9. 10. Particulars to be checked DD attached - verify amount, drawn in favour of concerned company and payable at Photograph pasted and signature across photograph Eligibility certificate for the category attached as applicable Notorised Affidavit as per Appendix - A as applicable attached Notorised Affidavit as per Appendix - B as applicable Notorised Affidavit as per Appendix - C Certificate as per Appendix - D as applicable Declaration by Applicant at the end is duly signed with name, date and place All pages of application are numbered and signed The Application is complete in all respect Appendix - A (NOTARISED 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 resident of (Name of Village), (Gram Panchayat), (District) in the State of ........................................ 2. That my date of birth is d d / m m / y y y y (in words___________________) Check Box

10.5 Details of the loan which can be obtained from Schedule Banks/Financial Institutions based on Bankers/Financial Institution certificate to extend loan as per Appendix-D. If no specific amount is mentioned then no marks will be awarded. Name and address of the Bank/Financial institution

D D

Date of Certificate

M M Y Y

Amount of Loan

(g) Applicants should provide only that information against various items of application, for which they are in possession of supporting documents in original as on the date of submission of application. Failure to present these documents in original at the time of verification will result in cancellation of selection due to submission of false/unsupported information. (h) The envelope containing the application, duly filled in, should be superscribed as under "This application is for Rajiv Gandhi Gramin LPG Vitrak at ........................... (location) of ......................... (Name of Oil Company)". (i) This is purely a business proposition and not an application for job in the respective Oil Company and has normal business risks and also does not guarantee any assured returns or profits. This is only an application and not an offer of RGGLV. APPLICATION FORM

(FORM TO BE FILLED UP IN CAPITAL LETTERS USING BLUE/BLACK BALL POINT PEN) PLEASE READ GENERAL INSTRUCTION TO THE CANDIDATES BEFORE MAKING THE APPLICATION

DECLARATION BY THE APPLICANT I am aware that evaluation of candidates will be done based on the information given in the application above. On verification by the Oil Company 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 RGGLV. 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. I am fully aware that after selection if I am unable to provide LPG Godown duly approved by the Office of Chief Controller of Explosives (PESO) and Showroom as per the Oil Company's standard layout, then the offer of RGGLV made to me will automatically stand cancelled. I am fully aware that I will not be appointed as RGGLV 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. I am aware that if married, my spouse will be co-owner of RGGLV with me. That, if selected, I undertake that I will deposit an interest free Security as per the policy of the Corporation. I have read the terms and conditions applicable for the RGGLV mentioned in the advertisement and confirm that I fulfil the eligibility criteria for the RGGLV I have applied for in this application. I, .................................................................................. daughter of/son of/wife of Shri ................................................................ hereby confirm that the information given above is true and correct. Any wrong information/misrepresentation/ suppression of facts will make me ineligible for this RGGLV. Place : ........................................ Signature of applicant .................................... Date : d d - m m - y y y y Name of applicant .......................................

(In block letters)

(j)

For Office Use

Not to be filled by applicant

D D Office Code Serial No.

-

M M

-

Y Y

Paste Passport Size Photograph with specimen signature on the photograph

Date of receipt of application

APPLICATION FOR RAJIV GANDHI GRAMIN LPG VITRAK YOJANA OF

Please write name of Oil Company of the location (BPC or IOC or HPC)

Particular of application fee

Rs. Date D D - M M - Y Y Payable At

Demand Draft Number Drawn on (name of the bank) In favour of (Full name of the oil company)

(Enclose Application processing fee of Rs. 1000/- (One thousand only) for all applicants except SC/ST candidate. Application processing fee for SC/ST candidates in Rs. 500/- (Five hundred) on enclosing SC/ST certificate) 1. 2. 3. 4. 5. Location (as mentioned in advertisment) Name of Tehsil or subdivision or block

(as mentioned in advertisment)

List of Enclosures : 1. Attested copy of Eligibility Certificate for the category applied. 2. Demand Draft No. ................................ dated ...................................... 3. Affidavit in original as per the format in Appendix A 4. Affidavit in original as per the format in Appendix B 5. Affidavit in original as per the format in Appendix C 6. Letter from Bank/Financial Institution in original as per format in Appendix-D Total number of pages of the application including attachments General Instructions to the candidates applying for RGGLV Item No. 1. 2. Instructions Supporting Documents to be provide by applicant at the time of verification

District State Category

OP, SC/ST, Combine Category (CC) Consisting of (DP/PMP/PH/OSP) Please attach copy of certificates as proof from the respective competent authorities as mentioned in the eligibility criteria. Not Applicable for locations under `Open' category. 6. 7. Advertised on

D D M M - Y Y Y Y

in (Please write Name of Newspaper)

Particulars of Applicant - Enclose Affidavit as per format given in Appendix `A')

First Name Middle name Middle Name Surname Surname

7.1 Name 7.2 Father's/ S H Husband's Name Title 7.3 Address

R I First Name

3. 4. 5.

Write the name of the location for which application is made as per advertisement Write the name of the Gram Panchayat of the location for which application is made as per advertisement Write the name of the district of the location for which application is made as per advertisement Write the name of the State of the location for which application is made as per advertisement Write the name of the category of the location as per the advertisement Write the date and name of the news paper in which advertisement has appeared for the location mentioned in item 1. For Item No. 7.1 to 7.8

Certificate issued by the competent authority. Caste validity Certificate as applicable

Pin Code Telephone No.

STD code Telephone Number

6. E-mail 7.

7.4 Indian Citizen Yes Revenue District State 7.5 Gender 7.6 Date of Birth 7.7 Marital Status 7.8 Name of Spouse 8 i. ii. iii.

No

Resident of

(Name of the village)

8.

Male / Female D D MM - Y Y Y Y

Age

Years

Months

Days

9.

Single

/ Married

/ Widow / Widower

/ Divorcee

Educational Qualification: Qualification Graduate Senior Secondary i.e. (10+2) CBSE or equivalent from recognised Board Matriculation i.e. Xth Standard examination or equivalent from recognised Board Note : Marks will be awarded based on the information given by the applicant on the educational qualification. On verification if it is found that the information given above is incorrect/false/misrepresented then the applicant's candidature will stand cancelled and will not be eligible for RGGLV. 10. 10.1 Board/University Year of Passing

9.

Details of land for construction of LPG godown & showroom The land should be suitable, in contiguous plot, freely accessible through all weather motorable approach road. The plot should be free from live overhead power transmission/ telephone lines. Pipelines/Canals/Drainage/Nullahs/Public Roads should not pass through the plot. The land should be in advertised location. Dimension of the land should be minimum 20 metre X 24 metre. Do you own a suitable land at advertised location for LPG godown & showroom? (Own means having clear ownership title of the property in the name of applicant/family member of the `Family Unit'. Family Unit' of a married applicant, shall consist of self, applicant's spouse and unmarried son(s)/daughter(s) and `Family Unit' of a unmarried Applicant, shall consist of self, applicant's parents and applicant's unmarried brother(s)/ sister(s) for the purpose of this entire application. In case of family member, consent letter from the family member will be required.) If `NO', Applicant is not eligible

YES

/

NO

Please strike off what is not applicable

Provide the following details. In case land belongs to member of `Family Unit', attach notorised affidavit as per Appendix-C.

Name(s) of the Relationship Date of registration Address of the owner of Land with applicant of sale deed/gift/ location of the date of mutation land for LPG Godown Khasra No/Survey No Dimension of land* Length in Metre Breadth in Metre

*Give the dimensions of the plot that will be used for proposed godown out of the total land owned. 10 Financial Capability Note : Marks will be awarded to the applicant on Financial Capability based on the information given below by the applicant on Annual Income, Amount in Savings Bank Account/ Investments, Value of Assets and Amount of loan from Banks/Financial Institution. On verification, if it is found that the information given by the applicant is incorrect/ false/ misrepresented then the applicant's candidature will stand cancelled and the candidate will be ineligible for this RGGLV. 10.1 Annual Income of Last Financial Year : Amount in words If you are income tax payee/payer mention PAN mumber Income pertaining to last Financial Year should be given. Attach notarised affidavit as per Appendix-B 10.2 AMOUNT IN SAVINGS BANK ACCOUNT as on the date of application in the name of applicant and members of 'family unit'. For the amount mentioned against the member of 'family unit' marks will be awarded based on the amount mentioned in the affidavit made by member(s) of 'family unit' the as per format given in Appendix-C. Sl. No. 1. 2. 3. 4. Name of Bank S.B.A/C No. Name of Relation with account holder(s) applicant Rs. Rs. Rs. Rs. Rs. Amount as on date of applicatiion · · · · · Rs 10.2

10.3

Notarised Affidavit-A to be submitted. A residency certificate in the standard format from the competent authority Education - Information in chronological order Original certificate for each qualification Details of land for construction of godown & showroom : In case applicant does not provide any information, then it will be deemed that applicant does not have required land and hence applicant will be ineligible for RGGLV Please provide the details of Land as per Registered Sale Deed/Gift Deed/ the format Mutation and government record etc. The date of the documents have to be on or before the date of application. Consent from the family member in form of Notarized Affidavit (Appendix-C) is required. Financial Capability Gross Annual Income of the "Family Unit" for Notorised Affidavit as per the last financial year. The income should Appendix-B and all the include income from all sources such as documents based on which the salary, property, interest, dividend, business/ income is shown in the Affidavit profession/vocation, agriculture and other sources, if any. If the applicant is an Income Tax Assessee, the details of income as shown in the Annual Income Declaration should conform to those indicated in the income tax return for the relevant financial year. If, however, the applicant is not an Income Tax Assessee then the details are required to be supported with other relevant document(s) some of which are mentioned below for illustration purpose only. a) Gross Salary : A certificate from the employer(s) indicating the total emoluments paid b) Income from property : Rent as declared and assessed for the purpose of tax. c) Interest on Bank Deposits : Letter issued by competent authority from Bank(s) showing the actual amount paid/credited as interest. d) Income from business/profession/vocation/ shares and other investment/other sources : Certificate from Chartered Account in support of the income indicated under each of these heads will be required. The applicant may also be required to produce any other documentary proof in support of the income indicated. e) Income from agriculture : A certificate from Mamlatdar/Tehsildar stating out clearly the location of the agricultural land the income there from. Amount in the Saving Account in the name of Notarised Affidavit as per self & the member(s) of the "Family Unit" as Appendix-C and Savings Bank on the date of application only will be Accounts Statement/Pass Book considered. Amount maintained in the joint from which amount as on the date account with member(s) outside the of application can be verified "Family Unit" should not be mentioned Investment in Fixed Deposit/Bonds/NSCs/ Notarised Affidavit as per Mutual Funds/Shares/ULIP value as on Date Appendix-C and original of Advertisement in the name of self and investment documents based on member of the "Family unit". which amounts has been Amount maintained in the joint account with mentioned in the application member(s) outside the "Family Unit" should not be mentioned and will not be considered. Fixed Deposit/Term Deposit etc in BankBank Statement or letter from the amount as on the date of advertisement should Bankers certifying the amount in be taken from the Bank FD/Term deposit as on the date of advertisement Investments in Mutual Funds/listed shares/ULIP based on the NAV on the date of advertisement. Value on the date of advertisement as certified by the Government Approved Valuer or the concerned financial institution/ certified by Chattered Accountant Certificate from the Insurance Company

3. That I have passed Std X or equivalent examination in the year y y y y and That I have passed Senior Secondary i.e.(10+2) CBSE or y y y y equivalent examination in the year* and That I have passed Graduation examination in the year* y y y y 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 RGGLV of any 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 RGGLV of any 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 or RGGLV of any Oil Company : OR That I am divorcee. That neither I nor my 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 or RGGLV of any Oil Company: 5. That I am of sound mental health. 6. 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). 7. That I hereby confirm that I was never 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. 8. 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 RGGLV or in this affidavit shall be found to be untrue or incorrect or false, the Indian Oil Corporation*/Bharat Petroleum Corporation*/ Hindustan Petroleum Corporation* would be within its rights to withdraw the letter of intent/ terminate the distributorship (if already appointed) and that I would have no claim, whatsoever, against the Corporation for such withdrawal/termination. * 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 therefrom. Solemnly affirmed and declared before me This ...................................... day of ....................................... Signature and seal of Magistrate/Judge/Notary Public Signature of person making affidavit (Name in block letters)

Appendix - B (NOTARISED AFFIDAVIT)

(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)

DECLARATION OF ANNUAL INCOME I,....................................................son/daughter/wife of .................................................. Age ........................... years residing at .....................................................do hereby solemnly affirm and declare details of my gross annual income as under : Please give details of income of the last financial year (20--/--) Gross income should be indicated and not net income Details of Gross Annual Income in Rupees Relationship Gross Salary Property Interest/ Business Professional Income Income Total (net Dividend (Net profit) Income from from other (I+II+ income) (Net of Agriculture sources e.g. III+IV+ expenses) (Net of pension, etc. V+VI+ expenses) VII) II III IV V VI VII VIII

I 1. Self 2. Spouse 3. Unmarried son/ daughter In case Applicant is unmarried, income of mother, father, unmarried brother(s)/unmarried sister(s) can be given in case notarised affidavit as per Appendix-C is attached Father Mother Unmarried sister(s)/ brotehr(s) I hereby declare that I am an Income Tax payer and I am attaching here with the copy of my Income Tax Return for the above Financial Year* I hereby declare that I am not an Income Tax payer* *Strike off whichever is not applicable Solemnly affirmed and declared before me This ....................... day of ..................... Signature and Seal of Magistrate/Judge/Notary public 1. 2. Signature of Deponent (Name in block letters)

It is important to give precise information under each head i.e. I to VII, if income under any head is NIL, then it should be indicated specifically as NIL and not left blank. If the applicant is payee of Income Tax, a copy of Income Tax Return should be attached. Appendix - C (NOTARISED AFFIDAVIT)

(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)

(To be given by the family member as defined in eligibility criteria other than applicant) I, ........................................................... son/wife/daughter of ............................................ Age .............................. years resident of .................. do hereby solemnly affirm and say as under : 1. That I am unmarried and my father*/mother*/unmarried brother*/unmarried sister* (Mr/Ms) ................................................................ (name) has applied for RGGLV of IOC*/BPC*/HPC* at .................................. (location) under `....................' category against the advertisement made in ............................ news paper dated ............................... OR That I am married and my unmarried son*/unmarried daughter*/wife*/husband* (Mr/Ms) ................................................................. (name) has applied for RGGLV of IOC*/BPC*/HPC* at .................................. (location) under `.......................' category against the advertisement made in .........................news paper dated .......................... 2. That in case he/she is selected for RGGLV I will provide financial assistance to the extent of Rs ...................................... which is mentioned at Item no.10 under my name in the application submitted by (Mr/Ms) ........................................... for RGGLV of IOC*/BPC*/HPC* at ............................................ That in case he/she is selected for RGGLV I have no objection for construction of godown/ showroom on the land specified in item no 9 in my name. * Strike off whichever is not applicable.

Contd. to next page

Total Total amount in words

Amount of money which applicant can get on surrender of Insurance policy or as loan against the policy as on the date of advertisment.

3.

Contd. from previous page

STANDARD FORMAT FOR SC/ST CATEGORY CERTIFICATE 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 Solemnly affirmed and declared before me This ...................... day of ..................... Signature and Seal of Magistrate/Judge/Notary public Signature of Deponent Relationship with applicant 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 below, issued at any time by a competent authority # notified by the Government of India, of the district in which his parents (or surviving parents) ordinarily reside who has been designated by the State Government concerned as competent to issue such a certificate. If both his parents are dead, the officer signing the certificate should be of the District in which the candidate himself ordinarily resides otherwise than for the purpose of his own education. In case of any doubt about the genuineness of the certificate, the same may be got verified through the concerned District Magistrate / Deputy Commissioner. The form of the certificate to be produced by Scheduled Castes / Scheduled Tribes candidates. This is to certify that Shri/Smt./Kum*............................. son/daughter* of .......................... of village/ town *.............................. in District/Division* ....................... of the State/Union/ Territory* of .......................... belongs to the ..................... Caste/Tribes and his/her religion is ................................. which is recognised as a Scheduled Castes/Scheduled Tribes under the Scheduled Castes/ Scheduled Tribes lists (modification) order 1956* read with the Bombay Re-organisation Act, 1960 and the Punjab Reorganisation Act 1956*. The Constitution (Jammu & Kashmir) Scheduled Castes Order, 1956* The Constitution (Andaman & Nicobar Islands) Scheduled Tribes Order, 1956* The Constitution (Dadra & Nagar Haveli) Scheduled Castes Order, 1962* The Constitution (Pondicherry) Scheduled Castes Order, 1964* The Constitution (Scheduled Tribes) (Uttar Pradesh) Order, 1967* The Constitution (Nagaland) Scheduled Tribes Order, 1970* Place : ............................. Date : .............................. Signature Name and Designation Office seal Date STANDARD RESIDENCE CERTIFICATE (To given by the selected candidate at the time of Verification) This is to certify that Shri/Smt/Kum ...................................................................................... son/ daughter/wife of ......................................................................... is a resident of ( name of town/ village) .................................... District ..................................... State ............................ for ........................ years. This certificate is issued for the purpose of applying for Rajiv Gandhi Gramin LPG Vitarak at ................................... . (............................................................) Date .................................. Place ................................ Signature of Dy. Tehsildar/Tehsildar Dy. Mamlatdar/Mamlatdar (Seal of Office) State/Union Territory* * Please delete the words which are not applicable. (Note : The terms "Ordinarily reside(s)" used here will have the same meaning as in Section-20 of the Representation of the People Act, 1950.) # Officers competent to issue Caste/Tribe certificates. i. District Magistrate/Additional District Magistrate/Collector/Deputy Commissioner/Additional Deputy Commissioner/Deputy Collector, 1st Class Stipendiary Magistrate/City Magistrate *** Sub-Divisional Magistrate/Taluka Magistrate/Executive Magistrate/Extra Assistant Commissioner. *** (Not below the rank of 1st Class Stipendiary Magistrate) ii. iii. iv. v. Chief Presidency Magistrate/Additional Chief Presidency Magistrate, Presidency Magistrate. Revenue Officers not below the rank of Tehsildar. Sub-divisional officer of the area where the candidate and/or his family normally resides. Administrative/Secretary to Administrator/Development Officer (Lakshadweep). STANDARD FORMAT FOR PH CATEGORY CERTIFICATE NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE Certificate No. Date Date I. Signature : .................................... Designation : ................................. (with seal of office)

CERTIFICATE FOR THE PERSONS WITH DISABILITIES This is to certify that Shri/Smt./Kum....................... wife/daughter/son of Shri ............................ Age ......................... old male/female, Registration No. ....................................... is a case of physically disabled/visual disabled/speech & hearing disabled and has .................................... % (.....................................) permanent (physical impairment/visual impairment/speech & hearing impairment) in relation to his/her ................................................................................... Note: 1. 2. This condition is progressive/non-progressive/likely to improve/not likely to improve*. Re-assessment is not recommended/is recommended after a period of ........................... months/years. *Strike out which is not applicable. Sd/(DOCTOR) Seal Sd/(DOCTOR) Seal Sd/(DOCTOR) Seal

Appendix - D (Format for obtaining Credit worthiness certificate from the Bankers, from a Scheduled bank/ Financial institution on their Letter Head and enclosed with the application. Please note that amount must be mentioned. If no specific amount is mentioned no marks will be awarded.) TO WHOMSOEVER IT MAY CONCERN Shri/Smt/Kum/M/s,..................................... is a customer of this bank for last................... Years and he/she/they is/are enjoying the following facilities from our bank/institution : a) b) c) During the above period, the dealings of Shri/Smt/Kum/M/s .............................with the bank and his/her/their conduct has been satisfactory. In case, RGGLV is allotted to him/her/them, we will be willing to extend a loan of Rs............ (In words ............) towards financing the same.

Signature/Thumb impression of the patient Countersigned by the Medical Superintendent/CMO/Head of Hospital (with seal) Recent Attested PhotographShowing the disability affixed here. STANDARD FORMAT FOR PARAMILITARY/POLICE/GOVERNMENT PERSONNEL CATEGORY Certificate is to be given by Head of the Office or an Officer not below the rank of Under Secretary to the Government on Official Letter-Head of the Organization/Government Office issuing the Certificate. NAME & ADDRESS OF THE INSTITUTE/HOSPITAL ISSUING THE CERTIFICATE Reference No. Eligibility Certificate for Paramilitary/Policy/Government Personnel Category This is to certify that Mr/Ms (name of applicant) ........................................ was working in our organisation ................... and has been disabled on (date) ..................... while performing duties at (place) ......................... OR This is to certify that Mr/Mrs ....................................... who was working in this office as .............. had passed away on (date) .................. while on duty at (Place) ............ Mr/Ms (name of applicant) ....................... (relationship .....................) was dependent on Mr/ Ms .............................. as per our records. Attested Signatures of applicant Place : ................................ Date : ................................ Signature Name : Designation : Office Seal :

II.

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