Annexure-4.1 (Ref. Clause 4.8) This form is available free of cost Application Form For Requisition Of Supply Of Energy 1. Name of the Applicant : 2. Father/Husband's Name : 3. Occupation : 4. Address : (a) For Communication (b) Where Connection is Required: (Indicate land makes to identify the location) 5. Plot size______ sq.feet covered Area________ sq. feet. 6. Total Connected Load: 7. Purpose of Supply: ______________ 8. Details of Processing Fee: (a) Amount (b) Mode_____ cheque / draft / cash i. No Date ii. Bank Name (Following Information is to be Furnished by Applicants Requisiting Electric Supply more than 50 KW and for Industrial Purposes) 9. Type of unit firm (Viz: ownership :-------------------------------------- / Partnership/ Private Ltd./ Public Ltd. / Society / Govt. Deptt. / Govt undertaking 10. Name of Institution developing Industrial Premises :------------------------------------ (e.g. UPSIDC/self/industries deptt. etc.) 11. Possession Letter or No. Objection Certificate :------------------------------------------ Issued by the Institution (copy enclosed.) No.--------------date---------- 12. Whether supply is needed through an independent feeders :----------------------- 13. Whether the above unit ever operated at some other place or applied for connection ? (If yes, pl. furnish the following) (a) Sanction load: :----------------------- (b) Service Connection No. :-------------- (c) Arrears of payment (in any) :----------------------- (d) Address 14. If electricity connection for the premises is being requested in the past. If yes details of electricity connection. (a) Name of unit :-------------- (a) Service connection no. :-------- (b) Arrears of payment (if any) :-------- 15. Purpose or process for which Electricity load is required. :-------------------------- 16. Nature of process :-------------------------- 17. (a) Registration No. from Deptt. of Industries U.P. Govt. :-------------------------- (b) No objection certification from Pollution Control Board (Copy to be enclosed.) :-------------------------- 18. Name of the Agency Financing the unit (UPFC/PICUP/BANK/SELF/Any other) :-------------------------- 19. Proposed date of start of Production :-------------------------- 20. Is there any other industrial unit operating in the vicinity If yes, please given name and address -------------------------- 21. Pl. specify voltage ratio & capacity of the nearest Electricity sub-station and its distance from the unit :-------------------------- Enclosures : 1. Work Completion Certificate and Test Report (B & L form) 2. Documentary evidence in support of lawful occupation of the premises. If the applicant is not the owner of the premises, indemnity bond as specified by the Licensee shall be enclosed. 3. Factory/Industry/Premises/Establishment/House map, where supply is desired, indicating tentative position of the meter box. 4. Receipt for payment, if cash/cheque/draft. 1. In case of consumers without MDI meter, the connected load can be 200% of the contracted load in the domestic category and 133 % of the contracted load in the commercial category. 2. In your own interest, please ensure permanent disconnection of your electric supply before vacating the premises 3. Electric Connection shall not be treated as a proof of ownership of the Premises DECLARATION I/we, ....................., solemnly assure and undertake that A. I/We hereby declare that I/we desire to have and agree with the Licensee to take a supply of energy for the above mentioned purposes, for a period of not less than 2 years from the date of commencement of supply and to pay for the energy so supplied and all other charges at the rates set out in the Tariff Order. B. I/We also agree to be bound by the Licensee's Distribution Code as approved by the Commission including any modifications thereof and the provisions of Indian Electricity Act, 1910 together with the Rules framed there under and Electricity (Supply) Act, 1948 in so far as they are applicable. C. I/We also declare that in the event of my/our failure to comply with the above provisions, it shall be lawful for the Licensee to discontinue the supply in terms of the aforesaid Distribution Code. D. I/We further declare that the Licensee shall not be held responsible for any interruption/diminution of supply for reasons beyond its control. E. I/We understand that this declaration can be cancelled after two years by either party giving notice as per the procedure described in this code. F. I/We further agree that this declaration given by me/us shall be construed as an Agreement with the Licensee to the above effect. G. I/We declare that all details furnished in the Application Form are true to my/our knowledge. If any information is found incorrect at a later date, then the Licensee shall have the right to withhold/ disconnect supply, as the case may be. H. It shall be ensured by me/us that there is no unauthorized addition/alteration to the equipment or theft or misappropriation or by-passing of or tempering of the meter. In other words, it shall be ensured by me/us that the energy provided to me/us by the Licensee is utilized as per law and authorization. In case the Licensee has reasonable basis to understand or apprehend that there is in any way whatsoever unauthorized addition/alteration to the equipment or theft or misappropriation or diversion of the energy or by-passing of or tampering with the meter, it shall be open to the designated authority of the Licensee to enter upon the premises for general inspection and testing of the equipment, meter and wiring etc. I. I undertake to intimate the Licensee as per the procedure described in the "Electricity Supply Code" whenever I intend to vacate the premises for which the electric connection is being taken. Date: ________________ Applicant's Signature Place: (To be Filled by the Licensee) 1. Date of application received: 2. Contracted Load Sanctioned: 3. Date of commencement of Supply: 4. Consumer No/connection No: 5. Meter No: Signature of Applicant Signature of Representative of the Licensee Acknowledgement Application form of Sh./Smt. -----------------------, complete in all respects/has following shortcomings, for requisition of supply is hereby received on -------------------. In this connection, the applicant is given a reference No.---------- to be used in all future correspondence. Signature of Representative of the Licensee Annexure 4.2(Ref. Clause 4.8) INDEMNITY BOND (if the intending consumer is not the owner of the premises) To: .......Engineer, From....... .......... ........... Whereas the land/premises detailed hereunder, belongs to Sri/Smt.....and I am only lessee/tenant/occupier of the said land/premises where I have applied for the electricity connection the said/premises and I am not able to obtain the consent of Sri / Smt........but produced the proof of occupancy, i.e. valid power of attorney/latest rent paid receipt/registered lease deed. Thereto I, in consideration of the grant of electricity connection to me on the conditions of supply for which I have executed the Agreement, further agree to indemnify and keep harmless the Licensee from all damages and claims whatsoever, including costs of suit, original petitions and all manner of legal or other proceedings that the Licensee may incur or likely to incur on account of any action of threat by or at the instance of the owner of the said land/premises (whether such owner be the said Sri/Smt.....or any other). I also further agree that such loss, damages and any other claim resulting out of the electricity connection being given to me without the consent of the owner of the land/premises are also recoverable from me and my properties under the provisions of the Revenue Recovery Act, in force at the time of such recovery, or by such other proceedings as the Licensee may deem fit to initiate. I hold myself answerable to costs of such recoveries and proceedings also. Place : Date: Witnessee:- Signature of lessee/tenant/occupier 1) 2)
