NGEP REGISTRATION FORM

NGEP

NGEP RETAIL OUTLETS SELECTION FORM

RETAIL OUTLETS DETAILS

Company Name

CAC Number

Name of MD / Authorized Rep

Office Address

Location of retail outlet

Contact Number

Contact Person

Website

DIMENSION

Station Size

Space for Autogas LPG

Space for Autogas L-CNG

Space for Autogas CNG

OTHER INFORMATION

State

LGA

SALES VOLUME (PMS) QTY

Daily

Weekly

Monthly

Quarterly

Annual

SALES VOLUME (PMS) AMOUNT

Daily

Weekly

Monthly

Quarterly

Annual

Interest in setting up gas skid conversion center:

Interest in accessing FG loan for NGEP:

OTHERS (PLS SPECIFY)

DPR License:

Yes

Number of Trainees (Maximum of 5 trainees per conversion center):

Amount of loan request (in words):

Loan Collateral

contacts: 08057875873, 08084875114, 08033426801, 07068082334