,Llsy fo|qr forj.k lkxj izk-fyESSEL VIDYUT VITARAN (SAGAR) PVT. LTD.

e-iz-iw-{ks= fo-fo-da-fy-fMLVhC;wku sapkbZt

ikoj gkl] fudV esu cl LVS.M] ".kxat okMZ] lkxj e-iz- 470001
vkosnu izi=&la;kstu fo'ks"k :i ls cnyus ds fy,
APPLICATION FORM FOR CHANGE IN CONNECTION PARTICULARS

fuosnu -

dk;kZy; iz;ksx gsrq

REQUEST NO.

(OFFICE USE)

vkosnu/APPLICATION FOR
u;k dusDku

vfrfjDr Hkkj yksM

uke ifjorZu@lq/kkj

New Connection

ADDITIONAL LOAD

NAME CHANGE/CORRECTION

DAMAND

REDUCTION OF LOAD

CHANGE OF CONTRACT DEMAND

LT

CATEGORY CHANGE

ADDRESS CORRECTION

ekax

Hkkj dh deh

fuEunkc

lafonk ekax dk ifjorZu

Js.kh ifjorZu

irs esa lq/kkj

mPpnkc
HT

miHkksDrk ekad@CONSUMER NO.:

[kaM 1-@SECTION 1. {ks= dk izdkj ykxw ij lgh dk fu'kku yxk,a @
?kjsyw
xSj ?kjsyw
DOMESTIC

Type of Area (tick one that applies)

ch-ih-,y-

COMMERCIAL

gkWVsy
d`i;k fy[ksa------

B.P.L.

xSj&okf.kT;d 'kS{kf.kd

HOTEL

NON COMMERCIAL EDUCATION

OTHERS/(PLEASE SPECIFY......

[kaM 2-@SECTION 2. vkosnd dk fooj.k ykxw gks og Hkjsa @

Applicant details (fill as applicable)

2-v- vkosnd dk uke O;fDr;ksa ds fy, ykxw QksVks igpku ds izek.k esa fy[ks vuqlkj
fyf[k,@laLFkku dk uke
2 a.
laLFkku gsrq ykxw
Name of Applicant (specify as mentioned in photo identity proof applicable for individual)/Organization Name (applicable for organisation)

lacks/ku

Jh

Jherh dq-

MkW- daiuh

Title

Mrs.

Ms.

M/s

i
z

Mr.

F
k

Dr.

2-c iq:"k L=h

esa

tUe frfFk

2b.

Date of Birth

Male

Female

firk@ifr dk uke
Fathers/ Husbands name

iz

fekW dk uke
Mothers Maiden Name

iz F
k

2 l-

Fk

vU; d`i;k fy[ksa-------

Others (Please specify.......)

v
a

fn fn e e o o

f
r

vk;q o"kksZa

D D M M YY

Age (in years)

va

fr

v
a

fr

fr

v
a
v
a
o

fr

vfrfjDr fooj.k laLFkku gsrq ykxw

Additional Details (Applicable for Organisation)

vf/kd`r gLrk{kfjrh dk uke

Name of Authorized Signatory
gLrk{kfjrh dk uke
Designation of Signatory

iz F
k
iz F
k

laLFkk dk izdkj fuxeu

Type of Organisation

2 n-

fuxeu frfFk
Date of Incorporation

f
n

f
n

ifjlj dk izdkj ykxw ij fu'kku yxk,a

Type of Premises (tick one that applies)

Lo;a ds LokfeRo esa

vU;

fdjk;s@is ij

daiuh iznk

ljdkj

iznk

Owned

Rented/Lease

Company Provided

Govt. Provided

Others

?kj dz@ Hkou dk uke

House NO./ building Name

xyh @ {ks=
Street/ Area

ySMekdZ
Lanedmark

kgj
City

nwjHkkk dz
Phone NO.

bZesy

Email Id

,l,l,u@ernku i= dzekad ;fn ykxw

gks =
SSN/ Voter ID Card No. if available

[kaM 3-@SECTION 3. ifjlj dk irk tgka fo|qr la;kstu pkfg,@Premises Address at which Connection is required
?kj dz@ Hkou dk uke
House NO./ building Name

xyh @ {ks=
Street/ Area

ySMekdZ
Lanedmark

kgj
City

nwjHkkk dz
Phone NO.

bZesy

Email Id

,l,l,u@ernku i= dzekad ;fn ykxw

gks =
SSN/ Voter ID Card No. if available

vkidh csgrj lsok esa gesa lg;ksx ds fy, d`i;k viuk lEidZ uEcj fy[ksa / Please Provide your contact number to help us serve you better

[kaM 5-@SECTION 5. VSfjQ Js.kh esa ifjorZu@Change in Tariff Category

fo|qr la;kstu dk iz;kstu@mi;ksx%@Purpose of Counnection:
orZeku Js.kh%@Current Category
ubZ vkosfnr Js.kh%/Now Applied Category:

[kaM 6-@SECTION 6. 3- Lohd`r Hkkj esa ifjorZu fd-okW-@Change in sanctioned load(KW)

orZeku Hkkj@
Current Load

Hkkj tqMko @ Load

Addition

Hkkj ?kVko @ Load

Reduction

vkosfnr fd;k x;k

Lohd`r Hkkj @ New
Sanctioned Load
Applied for

fo|qr la;kstu dk iz;kstu / Purpose/usage of connection:

?kjsyw miHkksDrk% i;k tksM+s x, Hkkj ds fu/kkZj.k gsrq izk:i Hkjdj layXu
djsa-@ Domestic Consumers: Please fill-up and attach format for determination of connected load.
lafonk ekax esa deh gsrq dkj.k @ Rason for reduction in contract demand.
[kaM 7-@SECTION 7. uke ifjorZu@lq/kkj@Name Change/Correction
uke ifjorZu
uke lq/kkj
NAME CHANGE

NAME CORRECTION

i;k lq/kkj ds fy, dkj.k crk,a@ Please specify reason for correction
7 v- vfrfjDr fooj.k laLFkku gsrq ykxw
Additional Details (Applicable for Organisation)

iq:"k

L=h

tUe frfFk

vk;q o"kksZa esa

Male

Female

Date fo Birth

Age (in years)

vkosnd dk uke O;fDr;ksa ds fy, ykxw QksVks igpku ds izek.k esa fy[ks vuqlkj
fyf[k,@laLFkku dk uke
iz

Fk

firk@ ifr dk uke

Father / Husbands Name

e
iz F
k

uke ifjorZu@For Name change

izdj.k

va
e

dkuwuh okfjl izdj.k

fr
e
v fr e
a

foh@[kjhn

[kaM8-@SECTION8. irk

Legal Heir case

Sale/Purchase case
lq/kkj@Address to be provided along with property proof/ownership

details
?kj dz@ Hkou dk uke
House NO./ building Name

xyh @ {ks=
Street/ Area

ySMekdZ
Lanedmark

kgj
City

nwjHkkk dz
Phone NO.

bZesy

Email Id

,l,l,u@ernku i= dzekad ;fn ykxw

gks =
SSN/ Voter ID Card No. if available

9v-@9a. lafonk dh ekax cnysa@Change of Contract Demand vkiqfrZ fo|qr dh vko';drk@Voltage at which
supply is required

11 ds-oh/ 11 KV
33 ds-oh- /33KV
132 ds-oh-/132 KV
220ds-oh-/220KV

9c-9b. vkosnd }kjk vf/k"Bkiu dh LFkkiuk gsrq vc rd mBk;s x;s dne% /Steps taken by the consumer so far to setup the installation:

9l-/9c.

1-/i.
2-/ii.
3-/iii.
4-/iv.
vkosfnr lafonk ekax ds iz{ksi.k dk vk/kkj%Basis of projection of Contract Demand Required
v/I. vuqekfur fofo/kdj.k dkjd/Diversity Factor assumed:
c/II. dqy lac) Hkkj/Total Connected Load: e'khuksa dh lwph layXu djsa%/Attach list Of machines:

9n-/9d. D;k la;kstu dks fofHkUu pj.kksa esa fy, tkus dh vko';drk gS% /Whether connection is required in
phases:

9;-9e. lafonk ekax ds pj.k

required

/ Phasing of contract demand:

ekad/S.No. vko';d lafonk ekax ds -oh-,-

fVIi.kh@Remarks

/CD Required(KVA)

laHkkfor fnukad tc ls vko';drk gS/Tentative Date from Which

9j-/9f. vf/k"Bkiu dk iz;kstu/Purpose of installation:

9y-/9g. VSfjQ dh p;fur Js.kh@Category of tariff opted for :
VSfjQ vkns'k ds vuqlkj/Category of tariff opted for:
9o-/9g. m|ksx dh mRiknu {kerk vFkok/Production of Industry? OR:
mRiknu dh laHkkfor frfFk Probable date of production
9i-/9h. m|ksx Js.kh/Category of industry
y?kq/SSI
e/;/MSI
o`gn@LSI
9Q-/9i. D;k e-iz- jkT; iznw"k.k fuokj.k eaMy] Hkksiky ls oS/kkfud vko';drkuqlkj vko';d vuqKk
vukifk tgk vko';d gks izkIr dh gS Wheteher 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.

;fn gksa rks izfr layXu djsa/(If yes, a copy should be funished):
9Hk-/9j.
iSu uacj mPpnkc dh n'kk esa vfuok;Z/PAN Number(compulsory in case of HT.)
[kaM10-SECTION 10 lHkh miHkksDrkvksa ds fy,@For All consumers
10v- LFkkuh; vf/kd`fr dh Lohd`fr@vuqerh] ;fn fdlh dkuwu ds varxZr vko';d gks
10 a.

Approval/permission of local authority, if required under any law

10c- D;k vuqKfIr/kkjh ds {ks=karxZr vkosnd ds uke ij dksbZ fo|qr cdk;k jkf'k gSA
10 b.

Any electricity dues outstanding in the licencee's area of operation in the consumer's name.

10l-

D;k bl ifjlj ij dks cdk;k jkf'k tgka fo|qr la;kstu gsrq vkosnu fd;k x;k gS

10c.

Any electricity dues outstanding for the premises for which connection appliced for.

10n- D;k ,slh fdlh laLFkk] vkosnd ftldk Lokeh] lk>hnkj] lapkyd ;k izca/k lapkyd gS] ij
vuqKifIr/kkjh ds {ks=karxZr dksbZ fo|qr cdk;k jkf'k gS10d.

Any electricity dues outstanding with the licencee against any firm with which the consumer is associated as an Owner. Partner, Director or Managing
Director. ekad 9c] 9l ,oa 9n ds fy, ;gk ^gk*
(For serial nos. 9b, 9c & 9d if answer is 'Yes' in any case please provide details)

gks rks i;k fooj.k nsa

[kaM11/SECTION 11. ?kks"k.kk/Declaration

eSa@ge ;s ?kks"k.kk djrk gw@djrs gSa fd@I/We hereby declare thatv mijksDr izi= esa fn;k x;k fooj.k esjh@gekjh tkudkjh ds vuqlkj lR; gS(a)

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

c eSa@ge us e/; izns'k fo|qr iznk; lafgrk ds fo"k;&oLrq dks i<+ fy;k gS ,oa mlesa
mYysf[kr 'krksZa dk ikyu djus ds fy, lger gw@gSa(b)

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

l eSa@ge fo|qr VSfjQ o vU; 'kqYdksa ds vk/kkj ij tks ykxw gksa fo|qr fcyksa dh
cdk;k jkf'k dk Hkqxrku izfr ekg d:axk@djsaxs(c)

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

n eSa@ge ehVj] dV vkmV ,oa mlds ckn dh laLFkkiuk dh izfrHkwfr ,oa lqj{kk ysus dh
ftEesnkjh ysrk gw@ysrs gSaA
(d)

I/We will won the responsibility of security and safety of the meter, cut-out and the installation thereafter.

fnukad%

Date

vkosndd @ izkf/kr gLrk{kjdrkZ ds gLrk{kj

Signature of Applicant/Authorized Signatory

[kaM11-/SECTION11. fuEuukafdr nLrkost tek djk,@List of documents to be submitted:

lHkh miHkksDrkvksa gsrq&ykxw ij fu'kku yxk,a@For All consumer-Tick one that applies
1

vkosnd@ gLrk{kjdrkZ dk iklikSVZ vkdkj dk

QksVks QkeZ ij fpidk,sa
Passport size photograph of Applicant/ Signatory (pasted on
form)

gkW
Yes

ugha
No

y-u
NA

fo|qr vf/k"Bku esa

cnyko@la'kks/ku@gVko dk fooj.k
ds lkFk vuqKfIr/kkjh fo|qr
Bsdsnkj ls dk;Z iw.kZrk
izek.k&i= vkSj ijh{k.k fjiksVZ]
tgka vf/k"Bku la'kks/ku gqvk
gks-

gkW
Yes

ugha
No

y-u
NA

Details of alteration/modification/removal of the electrical

installation with work completion certificate and Test report
from a Licensed Electrical contractor where alterationof
installation is involved

vkosnd@ izkf/kd`r gLrk{kjdrkZ ds QksVks

igpku dk izek.k layXu nLrksot fy[ks vkSj uEcj
fy[ksa sa
Proof of photo indentity of applicant / authorized
signatory specify document attached and mention
number
LokfeRo @ djts dk izek.k layXu nLrkost
fy[ksa
Proof of Ownership/ Occupancy Specifty document
attached mandatory for address correction