-----------------ASSAM POWER DISTRIBUTION COMPANY LTD.

Annexure 1: Applic !i"n n# A$ree%en! &"r% 'L"( Ten)i"n Ser*ice C"nnec!i"n +Re&er !" cl u)e ,.-.1.

(Please strike-off the purpose that is not applicable)

To, The Sub-Divisional Engineer Electrical SubDivision.

_____________________________ e!uisition for " (a) (b) (c) #e$ connection Te%porar& connection 'ro% E(isting )onnection (i) (ii) (iii) (iv) (v) (vi) E(tension of loa*+contract De%an* e*uction of loa*+)ontract *e%an* Shifting )hange in na%e+ )hange in categor& of consu%er ,thers (to specif&)

)onsu%er #o. (for e(isting consu%ers onl&)

Sir, - + .e re!uest &ou to suppl& electricit& to %& + our pre%ises (ne$ + te%porar& + e(isting connection for change as %entione* above). The re!uisite infor%ation is furnishe* belo$"

/.

#a%e of the 0pplicant(s) (-n block letters) -n*ivi*ual + 2ovt Deptt. +,ther organisation(specif&) (a) (b) #a%e of father + husban* (in case of in*ivi*ual) #a%e of Depart%ent + ,rganisation ($ith Designation of 0pplicant if applicable) Per%anent a**ress 5ouse #o. + Plot #o. oa* 6ane " " "

1. 3.

4.

(a)

0rea + )olon& " To$n+7illage " Post ,ffice "_______________________________________________________ District " P-# " Telephone #o " (if an&) E-%ail (if an&) ________________________________________________

(b)

0**ress of the pre%ises $here a ne$ connection is hereb& applie* for+ the e(isting connection is propose* to be shifte*" 5ouse #o. + Plot #o. "

oa* 6ane

" "

0rea + )olon& " To$n+7illage " Post office "______________________________________________________ District " P-# " Telephone #o " (if an&) E-%ail " (if an&) 4. (c) 'ull a**ress for correspon*ence an* sen*ing bills (if *ifferent fro% 4(a) or 4(b) 5ouse #o. + Plot #o. oa* 6ane " " "

0rea + )olon& " To$n+7illage " Post ,ffice "_______________________________________________________ District " P-# " Telephone #o " (if an&) E-%ail (if an&) ________________________________________________ 4. (*) P0# #o. (if an&) ___________________________________________________

8. (b) :.

(a)

9uilt-up area of the pre%ises_______________________ s! %etre 5eight of the 9uil*ing "

Purpose +)ategor& of suppl& "

;.

Propose* )onnecte* 6oa* " (a) 'or *o%estic, co%%ercial an* general purpose Suppl& " ___________________.atts (Please fill-up an* attach for%at 0ppen*i( 1 - for *eter%ination of connecte* loa*.) (b) 'or other categories please fill up the follo$ing (0ttach *ul& signe* separate list if re!uire*) L" # per i!e% +/(. T"! l l" # +/(.

I!e%

N".

<.

Distance fro% the nearest *istribution %ains to the e(pecte* point of connection "

(The above infor%ation provi*e* b& the consu%er $ill onl& be treate* as in*icative. During feasibilit& stu*& the 6icensee $ill *eter%ine the point of *istribution %ains an* the route through $hich the cable+ service connection $ill be *ra$n)
=. =0. 0n& electricit& *ues outstan*ing in 6icensee>s area of operation in consu%er>s na%e " ?es+ #o Details of an& other electricit& connection in the licencee>s area in the na%e of the consu%er ,if an&. 0n& electricit& *ues outstan*ing for the pre%ises for $hich connection applie* for " ?es+ #o

/@.

('or serials =,=0 A /@ if the ans$er is B?es> in an& case please provi*e *etails)
//. - + .e hereb& *eclare that the infor%ation provi*e* in this application is true to %& kno$le*ge.

- + .e have rea* the 0ssa% Electricit& Suppl& )o*e an* )onnecte* Catters egulations an* agree to abi*e b& the con*itions %entione* therein. - + .e agree to *eposit an a%ount as securit& *eposit for loa* an* also for %eter (if applicable) before the connection is provi*e* to %e an* also a**itional a%ounts fro% ti%e to ti%e as, %a& be *ue fro% %e, against *e%an* raise* b& the license, $ithin specifie* ti%e. - + .e shall *eposit electricit& *ues, ever& %onth, as per the applicable electricit& tariff an* other charges.

- + .e shall o$e the responsibilit& of securit& an* safet& of the %eter, cut-out an* other suppliers $ithin %& +our pre%ises the installation.

Date

"

Signature of the consu%er + 0uthoriDe* signature

Place

"

#a%e " Designation (if an&) " ,rganisation "

N"!e : The follo$ing *ocu%ents shall be attache* $ith the application " (a) Proof of legal occupation of the pre%ises along-$ith the cop& %ap of the pre%ises+ lan*, in*icating propose* point of suppl&, *ul& approve* b& the local authorit&. -n case of streetlights the location of street light poles shall be in*icate* in the %ap. 0pproval + per%ission of the local authorit&, if re!uire* un*er an& la$ + statute. -n case of a partnership fir%, partnership *ee*. -n case of a 6i%ite* 6icensee, Ce%oran*u% an* articles of 0ssociation an* )ertificate of incorporation. Proof of per%anent resi*ential a**ress of the applicant. Electrical )ontractor>s Test eport (-n appen*i( 3)

(b) (c) (*)

(e) (f)

N"!e : The )ontractor>s Test report %a& not be sub%itte* $ith the 0pplication but the supplier %a& re!uire at least ; *a&s ti%e for provi*ing the connection after receipt of the Test eport.

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A$ree%en! P r! ( #ot to be fille* up b& consu%er $hile sub%itting the application) /. #a%e of consu%er

1. 7oltage of suppl& 3. Single or three phase 4. )ategor& of suppl& an* tariff 8. )onnecte* loa* :. )ontract *e%an* ;. ,$nership of %eter <. Point of co%%ence%ent of suppl& =. E(tension +Service connection $ork $ill be *one b& licensee+consu%er(Delete $hich is not applicable /@. 0n& other %atter -n $itness there of __________________________________ (#a%e an* *esignation of 6icensees authorise* E(ecutive) acting for an* behalf of the Distribution 6icensee an* __________________________________________________ (consu%er) have hereunto set their han*s an* seal on this ____________ *a& of the %onth of ____________________ of the &ear ____________________.

,n behalf of licensee

)onsu%er #a%e an* a**ress

Signature Seal Place .itness / 1 .itness / 1