UNDERTAKING FOR LOSS OF LPG PRESSURE REGULATOR/CYLINDER

I, _________________________________ son/daughter/wife of Shri _____________________
aged _____ years, Resident of ____________________________________________________
and Indian inhabitant do hereby solemnly affirm and declare as follows:
1. That I am a consumer of HPGAS with Customer No. __________ being served through
their distributor M/s. ________________________________________ since ________.
2. That I have lost the LPG Pressure Regulator/Cylinder on ____________ (date), involving
_________________________________________________________(reasons for loss).
3. That I have neither given the pressure regulator / cylinder to any other person nor used it for any purpose against the guidelines issued by HPCL.
4. That I shall be liable to any action taken by M/s. HPCL in case this claim for loss of Pressure Regulator / cylinder is proved to be false, or it is found that I am involved in illegal use of the pressure regulator/cylinder.
5. That I undertake to return forth with the above referred pressure regulator / cylinder to M/s. Hindustan Petroleum Corporation Ltd., if found at any time.
SIGNED ________________________
(Signature of the Customer)
Place:
Dated:
IN THE PRESENCE OF:
1. ____________________
2. ____________________