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ANNEXURE -1

MADHYA PRADESH MADHYA KSHETRA VIDYUT


VITARAN CO.LTD. R- 1 No.:…………..

Date:………………..

APPLICATION FORM – HIGH TENSION/LOW TENSION SERVICE


CONNECTION

New Connection/Shifting of Premises/Change in


Contract

Demand/Change of Tariff Category/Change of Name of


Consumer

(Please strike-off the purpose that is not


applicable)

To,

----------------------------------------------

---------------------------------------------- Affix Pass Port

---------------------------------------------- Size Photo

Sir,

I/We request you to supply electricity to my/our premises. The requisite information
is furnished below :-

1. Consumer –
(a) Name of the person/organization : ……………………………………………………
(b) Name of father/husband/Director/ : ……………………………………………………
Partner/Trustee

(c) Full Address of the premises (with PIN)


Where a new connection is hereby
applied

for/ the existing connection is proposed to

be shifted

Telephone No. : ……………………………………………………

Registered Office (alongwith

Postal address) : …………………………………………………… Residence

(Postal address) : …………………………………………………… E-

mail : ……………………………………………………

Bank A/C No. and name of Bank : …………………………………………………… (optional)

Existing sanctioned load/contract

Demand if any, : ……………………………….………… (HT/LT)

Service connection no.

(For existing connection) : ……………………………………………………

LT Supply :

2. Built-up area of the premises/plot area : …………………………………………………

3. Category of supply : …………………………………………………………….

(Category as provided in the list attached)

4. Purpose of supply : …………………………………………………………….

(Sub-category as provided in the list attached)

5. Type of Supply : Permanent/Temporary


(Please strike-off type not applicable and tick the type applicable)

If temporary specify period – From : ……………………….. To : ……………………….

6. Proposed Load –

(a) For domestic connection : …………………………………………… Watts


Please fill-up and attach format for determination of connected
load.

(b) For other categories please fill up the following (Attach duly signed separate list if
required)
Item Load per item (Watts) No. Total Load
(Watts)

HT Supply

7. Voltage at which supply is required (KV) :

11 KV 33 KV 132 KV 220
KV

8. Type of supply : Temporary/Permanent

(Please strike-off category not applicable and tick the category applicable)

If temporary, specify period – From : --------------------------- To : ………………………..

9. Steps taken by the consumer so far to set-up the installation


(a) ………………………………………………………………………………………

(b) ………………………………………………………………………………………

(c) ………………………………………………………………………………………

(d) ………………………………………………………………………………………

10. Basis of projection of Contract Demand required –

(a) Diversity factor assumed :……………………………………………..

(b) Total Connected Load :……………………………………………..

Attach List of Machines

11. Whether connection is required in phases :……………………………………………..

12. Phasing of contract demand (CD) :……………………………………………..

SI.No. CD required (KVA) Tentative Date From Remarks


which required

13. Purpose of installation :…………………………………………………......

14. Category of tariff opted for :…………………………………………………..…

(as per tariff order)


15. Production of Industry ? OR :………………………………………………..……

Probable data of production

16. Category of Industry : SSI/MSI/LSI


(Please strike-off category not applicable and tick the category applicable)

17. Status of land acquisition :……………………………………………………

…………………………………………………………………………………………….

(Please provide proof of ownership and statutory clearances)

18. Expected date by which finance would be available : ……………………………………

19. Whether the requisite consent/NOC (where applicable according to the list of Pollution Control
Board) has been obtained from M.P. State Prevention and Control of Water Pollution Boards,
Bhopal as per statutory requirements

(If yes, a copy should be furnished) : …………………………………………………….

FOR ALL CONSUMERS

20. Any electricity dues outstanding in the licensee's area of operation in the consumer's name
Yes/No

21. Any electricity dues outstanding for the premises for which connection applied for :

Yes/No

22. Any electricity dues outstanding with the licensee against any firm with which the
consumer is associated as an Owner, Partner, Director or Managing Director Yes/No

(For serial nos. 20, 21 & 22 if answer is 'Yes' in any case please provide details)

23. I/We hereby declare that –

(a) The information provided in the form above is true to my knowledge.


(b) I/We have read the Madhya Pradesh Electricity Supply Code and agree to abide by
the condition mentioned therein.

(c) I/We will deposit electricity dues, every month, as per the applicable electricity
tariff and other charges.

(d) I/We will own the responsibility of security and safety of the meter, cut-out and
the installation thereafter.

Signature of the Consumer/Authorized Signatory

Date : …………………….……..

Place : ………………….……….

Note : The following documents shall be attached with the application form :-

1. Proof of ownership of the premises.


2. A map indicating therein in the proposed location of the plant/office and the point where
supply is required. The map should normally be of the scale of 1 cm representing 1200 cm
for HT connections.
3. Licensee/NOC from statutory authority, if required or a declaration by the applicant is that
his connection does not fall under the requirement of NOC under any statute.
4. In case of a proprietary firm, an affidavit to be submitted stating that the applicant is the
sole proprietor of the firm.
5. In case of partnership firm, a certified copy of partnership deed.
6. In case of Limited Company, Memorandum and Articles of Association and Certificate of
Incorporation.
7. Proof of permanent residential address of the consumer and PAN Number, if any. If there is
any change at a later date, the same shall be intimated by the consumer to the Licensee
immediately.
8. Letter of intent for production/enhancement in production for industrial connection.
9. List of equipment proposed to be installed along with the expected load.
10. Resolution for authorization in respect of where connection required in name of firm,
limited/Pvt Ltd firm, company etc.
11. Registration from Industries Department wherever applicable.
12. Extract of project report relevant to power and process requirement (in case of industries).
13. Copy of the relevant section of the current tariff order that provides details of the tariff
category opted by the consumer and duly signed by him. This will be appended with
agreement after completion of formalities.

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