PetroBonusTM Complaint Form (Customer copy) PetroBonusTM Complaint Form (Merchant copy)

Serial No. Date:

Serial No. D D M M Y Y Y Y
Member Name:
Date:
D D M M Y Y Y Y Petro Card Number: 7 2 4

Please remember to ask for a machine generated receipt when you submit ths Complaint Form
Member Name: Customer Account Number: C A

Petro Card Number: 7 2 4 Date of Birth:

D D M M Y Y Y Y
Place of Birth:
Options for complaint category (Please tick the appropriate
boxes) Mothers Maiden Name:
Address:
Lost Card (Please pay Rs.50 only)

Please tear and fold ap here

Change of address
Pincode:
Pin blocked (Please enclose the Card in the attached
envelope) Telephone Number: Mobile:
STD Code

Replacement of damaged card (Please enclose the Card in Email ID: ___________________________________@____________________________________
the attached envelope) Options for complaint category (Please tick the appropriate boxes)
Rewards not received Lost Card (Please pay Rs.50 only)
Petromiles statement not received Change of address
Other (Please attach all the details in an additional letter) Pin blocked (Please enclose the Card in the attached envelope)
I hereby authorize BPCL to send the card to the dealer and Replacement of damaged card (Please enclose the Card in the attached envelope)
deduct Rs. ____________________ from my Petro Card* for Rewards not received
sale of __________
Petromiles statement not received
Member Signature: ___________________________ Other (Please attach all the details in an additional letter)
I hereby authorize BPCL to send the card to the dealer and deduct Rs. ____________________ from my
For ofce use: Petro Card* for sale of __________

ROC No. Batch No. Member Signature: ___________________________

TID No. S A For ofce use:

Received Rs. ___________________ ROC No. Batch No. TID No. S A
Dealer seal & signature: ____________________________ Received Rs. ___________________ Dealer seal & signature: ____________________________

*Only in case where the dealer needs to receive the money for sale of fuel, which can not be *Only in case where the dealer needs to receive the money for sale of fuel, which can not be transacted on the Petro Card since it is blocked.
transacted on the Petro Card since it is blocked.