Before the Ld. Notary Public at …………………(Name of place)








I, ____________________, Son/D/W fo __________, aged about _____ years, residing at _________________________  (Address with pin code, P.O, P.S, Dist. and State) aforesaid solemnly affirm and state as under:



1)       Sri/Smt __________________, Son/Wife of _____________, resident of ___________________________(Address with pin code) has applied for Retail Outlet dealership at ________________( Address with pin code) Refinery Limited.


2)       I am having approx consumption of ____ KL per month of ______(Name of goods) required for my ______________________________(Name of Business).


3)       I hereby confirm that in case the dealership is awarded to above applicant, I will be taking my supplies through him to the extent of ____ KL per month subject to the commercial terms and conditions agreed mutually.


4)       I hereby confirm that this type of commitment has not been given to any other candidate applied for the above location.


5)       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 there from.


Solemnly affirmed and declared be fore me:


This ____ day of ______(month),________(year) .



_____________________                                                      ______________________________


   Signature and Seal of                                                            Signature of person making affidavit

   Magistrate/Judge/Notary public                                                   (Name in block letters)

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