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APPLICATION FORM FOR LIQUID PETROLEUM GAS (LPG)

IMPORTER/WHOLESALE LICENCE
PETROLEUM ACT (CHAPTER 13:22) LICENSING REQUIREMENT AND
STATUTORY INSTRUMENT 57, LPG REGULATIONS, 2014

SECTION A: APPLICANT’S DETAILS

1. Registered name in full

2. Trade name in full

3. Postal address of registered office

4. Physical address of registered office

5. Business telephone numbers

6. Mobile phone numbers

7. Fax number

8. Email address

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SECTION B: APPLICANT BUSINESS DETAILS

1. Registration number

2. Tax number

3. Indicate local ownership in percentage %

4. Wholesale Storage facilities owned or leased (use separate page if information

does not fit in the spaces provided)

Bulk Tank Storage Facilities

Physical Address Tank No Capacity

Mobile Cylinders Storage

Cylinder Size Number Total capacity

 Total bulk storage capacity to be at least 40 tonnes

 Total cylinder capacity to be at least 20 tonnes

5. Approvals and/or Certificates issued(use separate page if information does not fit
in the spaces provided)

Approval Issuer or Number Date issued

Local Authority
EMA
Fire Clearance

6. Volumes (litres) imported in last calendar year

LP Gas Bulk

LP Gas
Cylinders (kg
filled)

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 Enter projected volumes for the year
LP Gas Bulk

LP Gas
Cylinders (kg folled|)

SECTION D: DECLARATION

I (full names)…………………………….. hereby declare that all information

provided herein is within my personal knowledge and that –
(a) I am duly authorized to make this declaration;
(b) I am the designated person responsible for this Licence and any
conditions attached thereto;
(c) I have read and understood the regulations related hereto, with specific
reference regarding to any false declaration; and
(d) All information provided herein is to the best of my knowledge true and
correct.

Signed at……………………….. (Place) on this ………day of ………

(Month)……………. (Year)

……………………………………….
Signature

I certify that the applicant –

(a) Has acknowledged that he/she knows and understands the contents of
this application form and its conditions, that he/she considers the oath
binding on his /her conscience; and

(b) has in the prescribed manner sworn that the contents of this application
form and its conditions are true and signed before me at ……………(place)
on this………….day of…………….(month)…………year.

………………………………………………………………
COMMISSIONER OF OATHS

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Please also attach the following documents:

1. Certified copy of Applicant’s identity document;

2. Company registration certificate;
3. Certificate of Incorporation and CR14, CR 6, C R2;
4. Lease agreement;
5. EMA certificate;
6. Fire certificate;
7. Local Authority certificate;
8. Previous license (if applicable).

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