Annexure-4. 4(Ref. Clause 4.27) This form is available free of cost Application Form for Requisition of Temporary Supply of Energy 1. Name of the Applicant : 2. Occupation : 3. Address of the Applicant : 4. Address where connection is required : a. (Indicate land marks to identify the location) 5. Total Connected Load 6. Purpose of Supply: ______________ 7. (a) Date from which supply is required (b) Duration for which supply is required 8. Details of Fee (a) Amount (b) Mode_____ cheque / draft / cash (i) No Date (ii) Bank Name DECLARATION I/we, ....................., solemnly assure and undertake that a. I/We also agree to be bound by the Licensee Distribution Code as approved by the Commission including any modifications thereof and the provisions of Indian Electricity Act, 1910 together with the Rules framed hereunder and Electricity (Supply) Act, 1948 in so far as they are applicable. b. I/We also declare that in the event of my/our failure to comply with the relevant provisions of the Code, it shall be lawful for the Licensee to discontinue the supply. c. I/We further declare that the Licensee shall not be held responsible for any interruption/diminution of supply for reasons beyond its control. d. I/We further agree that this declaration given by me/us shall be construed as an Agreement with the Licensee to the above effect. e. I/We declare that all details furnished in the Requisition 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. Date: ________________ Applicant's Signature_____________ Place: (To be Filled by the Licensee) 1. Date of application received : 2. Contracted Load Sanction : 3. Date of commencement of Supply: 4. Reference No : Acknowledgement Application form of Sh. / Smt. ----------------, complete in all respect, for requisition of temporary 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
