Application to BPCL

S. No. Description Details to fill Remarks

1 Full name of StartUp LAKSHMI BALAA AGENCY PRIVATE RoC Certificate to be

LIMITED shown and a copy
submitted during
verification of
documents
2 Contact details of 9150368568
Start Up

3 Email id of Start Up gbmurugulakshmi1974@gmail.com

4 Start Up registration APPLIED To be checked on the
number (registration DPIIT Website
with DPIIT)

(if DPIIT registration

has been applied but
certificate not
received, Applicant
LO write "Applied
For")
5 Nature of PRIVATE LIMITED
consitution of the
Start Up
6 PAN NO. APPLIED FOR Original to be shown
and copy to be
submitted at the time
of verification

7 GSTN /VAT No. APPLIED FOR To be submitted at

the time of
verification

8 Name of the contact GUNASEELAN B

person of the Start
Up

9 Contact number of 9560998063

the contact person

10 Email id of the
gunaseelanb.ce133@gmail.com
contact person
11 Address of the 1/378 M1, GOPAL NAGAR,
registered office of SATCHIYAPURAM POST, SIVAKASIWEST.
the Start Up PIN- 626124

12 Address of Branch NA

For LAKSHMIBALAA AGENCY PVT LTD

Bb.twag
DIRECTOR
 Offices of the Start
Up

13 Name and Address of NA Consent letter to be

BPCL dealer uploaded
Territory which has
issued consent letter
for uplifting product
from Retail Outlet /
COCO

14 Details of online NO932323992651166 Transaction id /UTR

payment of non RS: 11800 number no.
refundable 03-04-2023
Application fee HDFC BANK
Amount (Rs.)
Dated of Transaction

Name of Bank

Page 1 of 3
" Notes:
"Qualification / Evaluation process:
a. Applicant should be registered with Department of Promotion of
Industry and Internal Trade (DPIIT), Ministry of Commerce &
Industry (MoC&l) on website www.startupindia.gov.in, Validity of
the registration certificate with DPIT will be verified from the
website www.startupindia.gov.in.
b. Start up which has applied for the DPIIT registration but is yet to
get DPIT certificate can also apply. However, the DPIIT certificate
has to be submitted at the time of verification of original
documents to be eligible.
c. Payment of Rs. 10,000/- +GST @18% (total amount =Rs. 11,800/-)
as application/registration fee is to be submitted online.
d. Applicant intending to take product from BPCL's supply location /
Retail Outlet should have indicated at least one BPCL Supply
location / RetailOutlet where it intends to uplift product in the
Mobile dispenser in the Application form
e. In case Applicant intends to take supplies from BPCL Retail Outlet,
consent of concerned Retail Outlet dealer will also be required to
be obtained by the Applicant in the format attached (Annexure 2)
and uploaded alongwith EO|.
f. In case Applicant intends to take suppliedfrom BPCL COCO, consent
AGENCY PVT LTD
For LAKSHMI BALAA
eb.eeeglah
DIRECTOR
 ofthe concerned Divisional / Territory / Regional office willbe
required to be obtained by the Applicant in the format attached
(Annexure 2A) and uploaded alongwith EO1.
8. Applicant has to produce original documents for verification within
the stipulated period as intimated by BPCL.

EOl not complying with the above eligibility conditions will be rejected.
Once an application is submitted, no modification or change will be
allowed.

Page 2 of 3

Auinorized Signatory
GB MURUGULAKSHMI
Designation : DIRECTOR
For LAKSHMI BALAA AGENCY PVT LTD
Stamp:
Date: 03-04-2023
DIRECTOR

This is to confirm that the information given above is true and correct and we shallbe liable
for any action/consequences including termination of FuelEnt Agreement if the information is
found to be false at any stage. Further, the documents referred to and provided are genuine
copy of its original and we are in possession of the original and shall produce the same as
and when called for by BPCL. For LAKSHMIBALAA AGENCY PVT LTD

b.Rerugdak
DIRECTOR
Place:
SIVAkASI (Sign. & Seal of Authorized Signatory)
Date: -0-da
Note:
1. The Start Up must submit all relevant documentary evidence with reference to above.
2. All the documents to be submitted by the StartUp should be self-attested. 3. Original
documents will be verified before signing Provisional Agreement.