Appendix - I
Notarized Affidavit for offer of finance by members of ‘Family unit’
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED VALUE)
(To be given by the family member as defined in eligibility criteria other than applicant,
for Finance)
I _______________________________ Son/daughter/wife of ___________________
age ______ years resident of _____________________ do hereby solemnly affirm and
say as under:-
That I am unmarried and my father* /mother* /unmarried brother* / unmarried sister*
(Shri / Smt / Kum) __________________________________ (name) has applied for
Service Provider contract of IOC* / BPC* / HPC* COCO at _______________(location),
dist '__________' against the advertisement appeared in
__________________newspaper dated __________________ / letter dated
_________ received from IOC* / BPC* / HPC* against nomination by DGR / Rajya
Sainik Board / Zilla Sainik Board.
OR
That I am married and my unmarried son*/ unmarried daughter* / wife* / husband*
(Shri / Smt / Kum) __________________________________ (name) has applied for
Service Provider contract of IOC*/BPC*/HPC* COCO at _______________(location),
dist '__________' against the advertisement appeared in ________________
newspaper dated__________________ / letter dated _________ received from IOC*
/ BPC* / HPC* against nomination by DGR/ Rajya Sainik Board / Zilla Sainik Board.
* Strike off whichever is not applicable.
That in case he/she is selected for the contract of Service Provider, I will provide
financial assistance to the extent of Rs. _____ lakhs, which I hold in my name, and
which is mentioned at Clause no. 3.1 of the application form submitted by (Shri / Smt
/ Kum) ___________________________ for contract of Service Provider of IOC* /
BPC* / HPC* at ____________________________
I hereby verify that what has been stated above is true and correct to the best of my
knowledge, and nothing has been concealed there from.
Signature
Name of Deponent and
Relationship with applicant
Solemnly affirmed and declared before me
This_________________________ day of ______________________________
Signature and Seal of
Magistrate/Judge/Notary Public
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Appendix - II
APPLICATION FORM
APPLICATION FOR ENGAGEMENT OF A SERVICE PROVIDER FOR
PROVIDING SERVICES FOR CORPORATION OWNED CORPORATION
OPERATED RETAIL OUTLET
Passport Size
Photograph
with specimen
signature on
the photograph
Location ______________ Rev. Distt. ________________ State ___________
Advertised on (Date) in (Name of Newspaper) by OMC (Name of Oil Company)
/ (IOC / BPC / HPC) letter dated (DD/MM/YYYY) asking for submission of
application against nomination by DGR / Rajya Sainik Board
1. Applicant Details:
1.1 Name (in Block Letters): Mr./Mrs./Ms.
________________________________
1.2 Address:
_______________________________________________________
_________________________________________________________
___________ PIN:___________ Telephone No.: ___________
E-Mail Address: __________ Mobile No: ____________
2. Standard affidavit: Enclose affidavit as per Appendix - III
2.1 Date of Birth: _______________ (Proof to be attached)
2.2 Father’s / Husband’s Name:
________________________________________
2.3 Citizenship/ Residential Status: Citizen of India / Resident of India
as per IT Rules
2.4 Educational Qualifications:____________________(Proof to be
attached)
2.5 PAN No.: ______ (Proof to be attached)
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2.6 Last Rank Held: ________________________(Proof to be attached)
(For nominees of DGR / Rajya Sainik Board)
2.7 It is confirmed that I am eligible to apply for Service Provider Contractor-
ship and meet multiple dealership norm as per the sr. no 3 & 5 of
Appendix ‘III’ enclosed.
3. Finance Details:
3.1 Details of liquid Assets: Give details of source of funds:
Finance (Please read Clause no. 5.2 of Brochure before providing the information below)
(Please attach copies of relevant supporting documents / certificates as applicable)
a. AMOUNT IN SAVINGS BANK ACCOUNT IN BANK/ POST OFFICE as on the date of
application in the name of applicant and members of “family unit”. Attach notarized
affidavit as per format given in Appendix - I from member(s) of 'family unit'.
S. Name of Bank S.B. A/c. Name of Relationship Amount in
N. No Account Holder with Applicant Rs. as on
** date of
application
TOTAL AMOUNT (in Rs.)
TOTAL AMOUNT IN WORDS (in Rs.)
b. Free and un-encumbered Fixed Deposits in Banks, Post Office, Listed Companies /
Government Organisation / Public Sector Undertaking of State and Central Government,
Kisan Vikas Patra, NSC (Redemption value of the instruments as certified by Chartered
Accountant will be considered. Certificate from Chartered Accountant to be attached.)
S. Type of Financial Reference Name(s) Relation with Initial Redemption
N. instrument - FD / NSC / Number of the applicant ** investment Value
KVP, etc. with date holder Amount (Amount in
Rs.)
TOTAL AMOUNT (in Rs.)
TOTAL AMOUNT IN WORDS (in Rs.)
c. Free and un-encumbered Bonds, Shares of Listed Companies in demat form and Listed
Mutual Funds (Certificate to be enclosed from a Chartered Accountant / Depository
Participant certifying the market value based on NAV on last working day of previous
month of application for mutual funds. For shares of listed companies in demat form, the
market value on last working day of previous month of application to be considered). For
46
these Funds only 60% of the value as certified by the chartered accountant / Depository
Participant to be given.
S. Type of Financial Reference Name(s) Relation Initial Certified 60% of
N. instrument - Number with of the with investment Value the
Bonds / Shares / date holder applicant Amount (Amount in certified
MF ** Rs.) value
TOTAL AMOUNT (in Rs.)
TOTAL AMOUNT IN WORDS (in Rs.)
TOTAL AMOUNT (in Rs.) (a+b+c)
TOTAL AMOUNT IN WORDS (in Rs.) (a+b+c)
** Please qualify the relationship “Unmarried brother”, “Unmarried sister”,
“Unmarried son”, “Unmarried daughter”, “Father”, “Mother”, “Spouse” etc.
wherever necessary.
Note: The funds mentioned above should be available with the applicant as on
the date of application.
3.2 Copies of current registration with E.P.F. and E.S.I.C. (if available) to be
enclosed.
4. Application Fee:
DEMAND DRAFT / PAY ORDER NO. _________________ dated
______________ for Rs.__________________ drawn on
__________________________(state Bank’s name) in favour of Indian Oil
Corporation Limited / Bharat Petroleum Corporation Limited / Hindustan
Petroleum Corporation Limited payable at _____________ is enclosed.
5. Undertaking:
I undertake to produce Originals of all the attachments enclosed with this
application at the time of verification of documents and whenever called for
and I am aware that in the event I fail to produce the Originals, my application
for service provider will be disqualified.
That, if selected, I undertake that I will furnish a Bank Guarantee of required
value as per the policy of Corporation. I understand that the subject contract
is for providing services during the period of contract. As per terms of contract
47
I will have no claim whatsoever on getting dealership for the subject COCO
location.
I,
_______________________________________________________________
____
hereby certify that the information given above is true to the best of my
knowledge and belief. Any wrong information / suppression of facts will
disqualify me from being considered for the service provider.
Place:_________________
Signature
Date: _________________ (Name in block letters)
NOTE : Affidavits to be enclosed in original. In respect of all other certificates
/ documents, duly self attested Photo copy / True copy ONLY need be attached
along with the application. However, originals of all these will have to be
brought at the time of verification of documents and if called for.
Encl : Total of _____ no. of documents with this application.
Encl : Checklist for supporting documents /affidavits etc. as per Appendix -
IV is to be filled in and attached on top of application form.
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Appendix - III
(TO BE TYPED ON APPROPRIATE NON-JUDICIAL STAMP PAPER OF REQUIRED
VALUE)
I, ________________________________________________ son / daughter /
wife of _____________________________ Age ________________ years
residing at ____________________________________________________,
applying for the COCO location__________________, District __________,
State _____________do hereby solemnly affirm and say as under :
2. That I am an Indian Citizen and a resident of India as per IT rules.
3. That I am unmarried. That neither I nor my Father, Mother, unmarried
brother(s), unmarried sister(s) have RO dealerships / SKO-LDO dealerships
/ LPG distributorships or hold Letter of Intent for RO dealerships / SKO-
LDO dealerships / LPG distributorships of any Oil Company (PSU as well as
Private Oil Co.) in individual capacity or in partnership with any other
individual.
OR
That I am married. That neither I nor my spouse, unmarried son(s) /
unmarried daughter(s) have RO dealerships/SKO-LDO dealerships /LPG
distributorships/ or hold Letter of Intent for RO dealerships/SKO-LDO
dealerships /LPG distributorships of any Oil Company (PSU as well as
Private Oil Co.) .) in individual capacity or in partnership with any other
individual .
4. I hereby also confirm that, neither I, nor any member of my “family unit”
is an employee or a retired employee of any Oil company.
5. I hereby also confirm that neither I, nor any member of my “family unit”
have service provider / contractor-ship for COCO operation or hold Letter
of Intent for service provider / contractor-ship for COCO operation of any
COCO of any Oil Company.
OR
That I, or member of my “Family unit” am/are holding the service provider
/ contractor-ship for operation of subject COCO.
6. That I have never been convicted by a Court of law for any criminal offence
involving moral turpitude / economic offences.
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7. I hereby confirm that I was never a signatory to a dealership /
distributorship / contractor-ship for COCO operation agreement of any oil
company, which was terminated for proven adulteration / malpractices.
8. That against item no. 3 of my application form with details of various
sources of funds required for COCO Service Provider-ship has been
furnished, I undertake that these funds will be made available for the
purpose stated above. In case it is found that the same is not made
available as and when required, the offer of contractor-ship, at any stage,
can be withdrawn and that I will have no claim / damages whatsoever
against the OMC (name of Oil Company).
9. That neither I nor any of my family members (family unit as defined in the
case of multiple dealership norms) is owning the land, wholly or partly, on
which the COCO Retail Outlet is constructed and for which I have applied
for the selection as Service Provider.
10. I hereby verify that what has been stated above is true to the best of my
knowledge and belief and nothing material has been concealed thereof. If
any information/declaration given by me in my application or in any
document submitted by me in support of application for the engagement
of contractor for Service Provider or in this affidavit shall be found to be
untrue or incorrect or false, Indian Oil Corporation Ltd. / Bharat Petroleum
Corporation Ltd. / Hindustan Petroleum Corporation Ltd. would be within
its rights to withdraw the offer letter / terminate the contract for Service
Provider (if already appointed) and that I would have no claim,
whatsoever, against Indian Oil Corporation Ltd. / Bharat Petroleum
Corporation Ltd. / Hindustan Petroleum Corporation Ltd. for such
withdrawal / termination.
_____________________
Signature of person making affidavit
(Name in block letters)
Solemnly affirmed and declared before me
This ___________day of ________________
______________________
Signature and Seal of
Magistrate / Judge / Notary public
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Appendix – IV
COVER NOTE OF APPLICATION: CHECK LIST OF DOCUMENTS
SUBMITTED
Name of the COCO Location / District:
Name of Applicant:
S.N. Document Particulars Page No. Submitted
Yes / No /
From To
NA
1. Attested copy of Certificate regarding Age
Attested copy of Certificate regarding Educational
2.
Qualification
Attested copy of certificate for last rank held (For Ex-
3. Defence Officers applying against DGR / Rajya Sainik
Board nominations)
Complete Filled Application Format with signature and
4.
photograph (with signature on photograph)
5. Affidavit as per Appendix-III
6. Attested copy of PAN Card
Attested copy of Photo Identity (Aadhaar / PAN card /
7.
Passport / Driving License / Voter id)
Attested document / affidavit regarding financial capability
8.
(liquid Assets) -
a. Fixed deposit/saving/etc
b. The finance / asset owned by the family unit - applicant
providing a consent from the concerned member from
the ‘family unit’ on notarised affidavit (Appendix–I)
along with supporting documents to establish the
capability.
c. Valuation certificates from chartered Accountant /
Depository participant etc.
Application Fee - Demand draft in favour of “Indian Oil
10.
Corporation Ltd. / Bharat Petroleum Corporation Ltd./
51
Hindustan Petroleum Corporation Ltd.” payable at specified
location
12. Any other document
Total no. of pages attached
Date:_____________ Signature of applicant
52
Appendix - V
COCO SERVICE PROVIDER AGREEMENT
SERVICE PROVIDER AGREEMENT FOR "COCO" RETAIL
OUTLET
THIS AGREEMENT made this _______________ day of Two thousand
and ______________ between _______________________ (Name of
OMC) a company incorporated under the Indian Companies Act, 1956 and
carrying on business at
_______________________________________________________________
hereinafter referred to as 'Corporation' (which expression shall unless
excluded by or repugnant to the context mean and include its successors
and assigns) of the ONE PART and ___________________ son / daughter
/ wife of ________________ residing at
___________________________________________________________
___________ carrying on business as sole proprietor Under the name
and style of M/s.________________________ and having its office
at_______________________________________ hereinafter referred
to as 'SERIVCE PROVIDER' (which expression shall unless excluded by or
repugnant to the context mean his/her heirs, executors and permitted
assigns) of the OTHER PART
WHEREAS Corporation is having COCO Retail Outlet for the sale of Motor
Spirit , High Speed Diesel and other petroleum products
at___________________________________in the district/town of
___________ in the State of____________________ AND WHEREAS the
Corporation is the owner / lessee of the plot of land and otherwise having
right to use the said land (herein after collectively referred to as the
“premises") and has installed at the said premises, buildings,
improvements and the equipments (herein after called "the outfit").
AND WHEREAS the Corporation intends to engage the "Service provider"
for providing various services at the said COCO Retail Outlet to be
operated by the Corporation itself on the following terms and conditions:
-
1. The Corporation hereby appoints the Service provider for providing
various services at the above referred COCO Retail Outlet with the
objective of running the Retail Outlet through its officials in a
smooth manner.
2. The Service provider hereby covenants and agrees with the
Corporation as under:
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