CONSENT FORM
REVISION NO.00
Purpose
: For adjusting payment dues of Defaulter customers against their SD/CSD.
Client
: INDRAPRASTHA GAS LIMITED
Contractor Name
: _______________________________________________________
BP NUMBER
ADDRESS
TELEPHONE NO.
METER NO.
METER READING
AMOUNT DUE(Rs.)
CUSTOMER DECLARATION
I hereby declare to get my IGL png connection disconnected permanently and request to deduct the balance
payment amount (pending bill payments towards IGL) from my security deposit (SD/CSD) with IGL.
Customer’s Signature
Contractor Representative Signature
Name
Name