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Power Supply Application Form A-I (Industrial)

New Connection D ~I!>. (~~~~/~'I'!R~~:"<IT)

I-"'~---"""-""""---"---:---:-----:D=----i Consumer No. (Neighbour's for New Connection I Self for Additional Load)

(31fufl:<ffi ~ ~ ~ 'li'm 1!:(~) q <r ~ <rffi ~ ~.) (In case of Additional Load only Tables A (1) & B are required to be filled)

~~~~ (~~~3llfUr'f(i'ld<tli4IW Subject to the provisions of MERC Electricity Supply Code

~-~oo,",~~~~W~~~ & other Conditions of Supply & SOP Regulation, 2005.

"&Wft~~~~~~Pqd<tlflld1/~ .rr/~~<wf am-/~.

I/We hereby submit this application for New connectionl Additional load for supply of electrical energy at the premises mentioned below.

fc:u:luft : - cpr:rr <itr<t" ~ -miT~ CfiU er ffi1l ~ ~~. Note: Please tick ~ appropriate box and strike off which is not applicable.

Details of Applicant and Premises{*- ~TcOR Mandatory Fields}

1) *~ "'1"lCf«JCil<f; 31&RTif) '(311Ci5@q~l~qlol) ;nqFirstname ~/<riitif;nq Name of Father/Husband 3lT&!iq Surname

Applicant'sName (INBLOCKLETTERS)
(Asper the proofof Identity) OR/AND
1) *~ I ~"'1"lCf «JCil<f; 31&RTif) Firm/
Company's Name (INBLOCKLETTERS)
2) ~;;wftcibr~~ am- ~~"tffiT (cpr:rr~ ~WIT - CfilfufCfilTI~ ~ ~~ ~ ,,@~q"1II(l4IU')* Address of
premises at which supply is required (Please furnish complete details - Minimum as per the Address proof)
"flCf1!>. ~SP.
Survey No.: Plot No.: r

~/~~~ ~:
Lane I StreeU Landmark: Taluka:
fmq m~ Pin Code
District:
3) ~"tffiT I~I!>·: I~I!>·:

I~:~~
Emailld: Phone No: Mobile No:

I ~D
4) ~ ~ / W (cpr:rr ~CfiU)
*~"\ICflR
Type of premises Self Owned
D Rented Occupier I Other (PI. Specify)
D
B . ;;ft. ~ y>~qi3<t1-JI1'fllTO"ll
Power Supply Requirement

~
LT
ffrlI'r
Single Phase
*'" D *'"
Three Phase
D ~
HT D

~*!!'1T< / ~KW ~ i<Ir& lWruft ~KW ~ '1T<IlWruft ~KW

lWruft ~KVA New/ Additional ~KVA TotalLoad!Demand ~KVA
Existing sanctioned Load demand
I Demand

c. -m. ~ Declaration:
!IT/~ 3Rl~mqit; I/we make the following declaration; that I/we shall
• ~ ~ ,oo~ 3l1fUr~ ~ ~ 3ll1ITTr(~'!NclI <ifunr 3l1fUr~ • Abide by the provisions of the Electricity Act 2003 and Maharashtra
w 31i\ ) fuf.!<rl! ,00'-1 lltfu;r ~ 'ffi'R m f<H;. . Electricity Regulatory Commission (Electricity Supply Code and other
conditions of Supply) Regulation 2005.
• W2lT'''IT fcmuft ~ ~ lWruft ~ ~ <<ITfcmuft ~ ~ 3W<'l[ffi :ornt •
Pay all electricity arrears (if any) of the premises for which I am / we are
~'R1lllf<'lT/~~~q~~3W<'l[ffilf<'lT/~ availing the electric supply. .
~ ~ '!NclINrourrr'lT(i\. "iT'IT'I<! If<'lT/ ~ 31'l'T<f~ 3lR'!~. •
Pay for the consumed electricity based on the prevailing tariff rates of
• 4~lfqt1{OliAllI""i'Ilffif~~, <iFr~"'*rr 'f{UTTm f<H;.. MSEDCL.
• ~ fqf~q41~1{ ~ munt o3'F'l" 3lT'fir{"i'Rfq~ *t< ~ Wlftut 3lT'fir{ 'lim • Pay for all other charges as they become due in accordance with above
'f{UTT q;ffi ~ . regulation and approved schedule of charges of MSEDCL.
Deposit such security as MSEDCL may be entitled to recover from me/us
• ~ ~ q fuf.!<rl! ~ 1i$I(qct(OIMI ~ ~ ~ 3R'JIRf ~ '1RUTT •
under the above Act and Regulations.
m/~.
 • ~ 1lWlT / 3lJ1I"IT ~ "<il"I 'IWcll ~ WIR ~ ~ ~ • Undertake to avail supply within one month from the date the MSEDCL
1«j; ~ ~ ~ ~ ~ ~ ~ -.tn ~ "~If,,,,(UI('11 <'I1'l intimates that it is ready to supply to our premises failing which I/we
~ fm "<il"I3Il<m: ~~-.tn. undertake to pay the MSEDCL the fixed charges as may be applicable.
• Have obtained all required statutory permissions for availing an electrical
• 'IT ~ ~ 'IWcll ~'liT'mR ~ ~-wt ~ ~~ supply. I promise to fulfill all the statutory requirements from time to
~.1l13ffi qq.{ ~ 'liI, ~ -wt ~
<'IT'T"1P'IT ~ '!.ffirr 'fiB. ~ time. I also undertake that MSEDCL will not be responsible for any
3ffi qq.{ ~ 'liI, <ril<1~ ~ Cl ~ m>ft "Il: ~ m<::~ ~ issues arising due to non compliance (if any)] of adhering to these
"'«IT~ ~ ~ wurrr'lTit. statutory permissions.
• ~.'l"{ ~ 1lWlT / 3lJ1I"IT 'lIc!]q( "flIT~ ~ -3RJll(f ~ -3j?jqf 'IT'Iit • In the event of death of individual I/We hereby nominate to receive or
~~~=~W:rr~~1l1/3lfIit~
adjust the deposit outstanding in my/ our name to
Shri/Smt/ _
~~q;"fur~/~.
• The above information is true and if any false information is observed, I
~~--------------------------------- [we will be fully responsible for the same.
• <ril<1 -wt ll1Wcft 19i\ 3Rf! «ITi1 <t>® ~ ll1Wcft ~"f'IR!I3t 111/ 3lfIit 'l."ffi:
~<TliR.~
~~t!Ct~lf\~~.
All submitted documents are verified by me.

(1i.u.fu.fu.ci;.1i.,"CZIT~-;:rtq, smcn:rgr) 3~ -m.ftq~

( Name, Designation & Sign of Representative of MSEDCL) Signature of Applicant & Date

D. it. ~ ~ Important Note;

~ ~c'lf<i{\fB<'.l~~~"'<.."i'ZlTR<r:r't"'~~~,~Wrr~~ ~ W'lm<filB"'RC!RT ~ ~ ~
'fi1{'R{""I~ anfUr~ ~ WlJ1lm"'3ffiU1T-<rr
~ ~ ~@~mlf~lql'l cft;;r ~ ~ 31'lfCIT IWli'IT/ 'IW~ ;mrr ~~, tfui, 'I'pf, m, q;lf\~
~~~q~~'fiTllCjljOffiTcft;;r ~~<f;Jl1,~<ROT,~ 31lfO'r~ ~~~ ~~
~~~ <f;Jl1'f>{ITI:ITff<tl;~.
Under Rule 45 of the Indian Electricity Rules, 1956. No electrical Installation work including additions alterations repair and adjustment to an existing installation
except such replacement of lamps, fans, fuses. switches, low voltage domestic appliances and fittings in no way alter its capacity or character shall be carried out
upon the premises of or on behalf of any consumer owner or occupier except by an electrical contractor licensed in this behalf by the State Government and under
the direct supervision of person holding a certificate of Competency and by a person holding a permit issued or recognized bv the State Government

E. ~. ~~ ('Pf'IT~ <%"T'!><T)
~ Documents Attached (Please Tick)
a.~.~'lW'T b. .rr.~~~~~ c.m.~~~~~~. Documents
Address Proof Other documents required at the time of required before release of Electrical Connection
application
~. ~ 1lJg<6i'fifhll (For LT consumers)
~~ • *'"IJtsuft~ ~ (~ it-~)Installation Test
'''!fITPIT('1~'1T-~~ 'qIS'fi{l{lfl~ <iiq;fr~'fi«lRT~ ~~
Report (0-1 Form)
(~~~)Wrr<fH~'iTi" ~ ~ ~~<if.ll(1'1I(1'l ~ • ~~ ~ Capacitor Test Certificate
~ Owners NOC (If the applicant is ~ Certificate of Incorporation from
tenant)1 Three month house rent receipts. Registrar of Company IDIC Certificate ~. ~~ '.ll(:ctlictlfhu (For HT consumers
Only)
<!liMI<'1~Chl~~ • ~~~/~.-wcit. Listof
(Anyone of the following documents) ~~~~"{i.~oo/-"i'ZIT Machinery with HP I KW _
~ ~~ ('1lflT-~ Wrr.!) • ~q'fll1l(1"~lJUl'fi<1'ffiT KVA MD Calculation
"{l?1Tf-lq; "\l~'Ii"{~ Local Authority If any of the above document is not Sheet.
Tax I Receipt available then affidavit on Rs.200/- stamp • *'"IJtsuft~ ~ (~ it-~)Installation Test
paper should be submitted. ( format -2 Report (0-1 Form)
~ifc!cIfr'f><T{ Purchase I Sale Agreement enclosed) • ~ ~ <ii'i'iT 'RCfRTft Permission from Electrical
Inspector
;;p:fR~~/~~~ • ~~~~~ Manufacturers
Test Certificate
~ 'f><T{Developer Agreement with Land
~, ~ Transformer, etc.
pwnerl Occupierl Govt. Agency

~~~ mWrriS/~~"3\1RT
Govt. Issued Property Card or 7/12 Extract

~~"r4CIT~3~~~
'lUqT Any document for proving owner or
occupier of premises.

furfuiT (Note) :-
m ~t!Ct ~ 'fiI'IGq~lfI~ <fH~ (l{<I>1f?'q;;R~) ~tnit. '"~ (l{<I>1f?'q'lT{ ~) 6<'f.lGI"Ifllal~'f>{ITI:ITff<rrqj (This form is to be
submitted along with all the required documents in triplicate (one original & two copies) for LT connections and in 5 sets (1 original & 4 copies for HT)

..............................................................................................................................................................................................................................

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