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UTTAR HARYANA BIJLI VITRAN NIGAM

Sales Instruction No. U- 15 /2014
From
The Chief General Manager/Commercial,
UHBVN, Panchkula
To
All CEs/(OP)/SEs(OP)Xens/SDOs/op,
JEs-I, Incharge in UHBVN
Memo No.Ch- 03/TR-90/ Cons Indexing /2/CGM/C-I
Dated:0407.2014.

Subject: Application & Agreement form in respect of new connection,

reconnection, extension/reduction of load & change of name.

The copy of redesigned Application & Agreement form (4 pages) in

respect of new connection, reconnection, extension/reduction of load & change of name

is enclosed herewith for compliance.

This supersedes the earlier issued A&A formats.

The above instructions should be brought to the notice of all concerned for
careful and meticulous compliance please.

DA/As above

General Manager/Comml.,
for Chief General Manager/Comml.,
UHBVN, Panchkula
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APPLICATION & AGREEMENT FORM IN RESPECT OF NEW CONNECTION,   
RECONNECTION, EXTENSION/REDUCTION OF LOAD & CHANGE OF NAME   
   
Photo 

 
                                                                     (For office use only) 
Name of the Sub‐Division     Applied for self        Govt. Org. 
Application No.     Semi Govt. Org         Private Org. 
Date of Receipt    If Govt. Org. than Name 
To be filled up by applicant in Block letters in blue or black ink; strike out whichever is  not applicable)
1.  Applicant’s Name (In Capital) Mr.      Ms.                                   
                                 
2.  Father’s/Husband’s Name                                   
3  Full Address of  House/Flat /Floor No.                                   
the premises at  Street Name                                  
which supply is  Colony/Locality                                  
required  City                   PIN Code No.           
4  Telephone No (with STD Code)                         
  Mobile No.  +  9    1  ‐                   
  E‐mail address   
5  Permanent  House/Flat (Floor) No.                                   
Address  Street Name                                   
Colony/Locality                                   
City                          PIN Code No.     
6.  Profession  Government Employee    Other     
(If Govt. employee) than Name of Department.   
(If Govt. employee) Connection In the name     Self           Wife      Guardian      Son    Daughter           
7  Bank Account No. (If any) 
 
With Name  IFSC Code & Address of Bank 
8  ID Proof   Ration Card    Voter Identity Card Driving License Receipt of House Tax     
(Any One)  Chulla Tax    Aadhar Card     
9.  Details of any other connection  Category    Account No.   
in the name of applicant (If any)  Address :   
10  If any other connection in the same premises   Category    Account No.   
11  If Tenant,  Name                                   
Landlord’s  House/Flat (Floor) No.                                   
Name &  Street Name                                   
Address  Colony/Locality                                   
City                  PIN Code No.             
12  DS  Residence    Worship Place    Village Chaupal     If Others than Name   
Shop    Business  Educational Hospital Cinema    Street Light HUDA & Anaj Mandi   
N D S  House  Institution  Clinics  (not handed over to MC) 
Malls            Hotel  Petrol Pump   If Others than Name  
AP  Irrigation Pump    Fisheries Horticulture    Tube Well    MITC    Lift Irrigation    
Category  
of  HT        LT                 Bulk Supply Railway Traction  Independent Hording  If other Category 
Connection 
Other  Domestic  Other  Railway DMRC Decorative Light  Than Name
Nature of Industry 
Street Light        PWW 

13  Type of Connection  :                               Permanent                 Temporary 
14  Connected Load / Contract Demand, applied for  Load declared by      KVA KW Load found at  KVA KW
 (in KW / KVA) (BHP in case of AP)   Consumer                  the time of site 
(Furnish details in table at page 4)  verification     
 
15  Whether,     New Connection         Reconnection Extension of Load     Reduction of Load   Change of Name  

16  Existing Account No. (If any)                            Category                                             Account No.
17  Installation test report issued by Licensed Electrical wiring contractor                 Attached  Yes Not
 is required to be attached except DS & NDS connection having load less than 20 KW     
18  Tick the relevant category :  General  SBC BC OBC     SC      ST
19  In case of BPL (Below Poverty line). Copy of Ration Card Attached                                  Yes    Not attached
 
                                                                                                                                            
              Date :                               Signature of Applicant 
PAYMENT MADE WITH APPLICATION
Received on behalf of  Uttar Haryana Bijli Vitran Nigam an amount of Rs.__________________ as a processing charge for connected load of ____________KW 
at ____________ Voltage level for a _______________________ category connection. 
Received Rs._________________(Rupees________________________________________________________) 
Vide Receipt No._________________________ Dated_________________________________                                              Signature of Cashier 
 
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CERTIFICATE OF SITE VERIFICATION 
Certified that I have personally verified the premises of the prospective consumer as detailed below : ‐ 
1. Name of 11 KV Feeder   
2. 14 Digit Feeder Code as per Indexing                              
3. Name of Distribution T/F (SOP)   
4. Capacity of Distribution T/F (KVA)               KVA  4 Digit Distribution T/F code as per indexing        
5. 18 Digit CIN No. (14 Digit Feeder code + 4 Digit DT 
code)                                     
6. Property Situated in which Area   Authorized                 If Unauthorized, than 
(fill the relevant box)                                       Area with Sq. yards          
7. Detail of any other connection and defaulting amount   
with A/C no. existing in the premises or in the name 
of applicant at any place if any otherwise fill NIL 

8. LL‐1 No. if any, otherwise write NIL   
9. Concerned LDC,give the detail of amount due   
against the account No. & Name mentioned at 
Sr. No. 7 with dated signature, if any otherwise 
fill nill.  
10. If, Extension/Augmentation of Distribution system is  Estimate No.                                                                             Nil 
required, than mentioned the estimate No. otherwise 
fill Nil.  

11. Ledger/Binder code of other consumers on the   
above mentioned DT/Area 
12. Any other remarks:   
13. Checked by Line Staff  Counter signed by JE  
Signature : 
Name: 
Designation :                      Date: 
 

AUTHORISATION FOR CONNECTION (For Office Use Only) 
Accepted & Approved on behalf of the Uttar Haryana Bijli Vitran Nigam for connected load of __________KW at ________ Voltage level for 
__________________ category connection. 
Detail of load sanctioning  authority :                       
Name of Sanctioning Authority  Designation  Signature with Date 
     

  
The above mentioned estimate has been approved vide estimate No.__________________ dated____________ 
Name of Sanctioning Authority  Designation  Signature with Date 
     
 

PAYMENT MADE IN COMPLIANCE OF DEMAND NOTICE 
Accepted on behalf of Uttar Haryana Bijli Vitran Nigam for connected load of ____________KW at ____________ Voltage level for a  _______________________ 
category connection 
Cashier to accept on account of the following: 
Date_________________                                                                                           Signature____________________ 
 
No.  Item  Amount 
1.  Advance Consumption Deposit (ACD)   
2.  Meter Security/Meter Cost   
3.  Service Connection Charges   
4.  Other Charges   
  Total   
 

Name_______________________ Designation___________________ Signature___________ 
Received Rs._________________(Rupees_________________________________________________________________________) 
Vide Receipt No._________________________ Dated_________________________________ 
 

The Account Number allotted to applicant is _______________________________ 
The Service connection order number is__________________________________ 
Name___________________________________  Signature________________________________ Date_________________ 

 
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DETAILS OF CALCULATION OF LOAD TO BE FILLED BY APPLICANT (Norms liable to revise from time to time)
Sr. No. of points Total Load
No Particulars (In KW)

For
office
use
only
1 Light Points (40 watt each)

2 Fan Points (60 watt each)

3 Wall socket (5 Amp) (6 sockets or part thereof=40 watts)

4 Wall Socket (15 A) (6 sockets or part thereof =1KW)

5 Rose Outlets for light Point

(i) For DS: - 1 to 5 rose outlets (40 watts); 6 to 10 rose outlets (2 x 40 watts)
(ii) For NDS: - 40 watt for each rose outlet

6 Air Conditioners through wall socket (take actual load as per capacity)

7 Geysers through wall socket (take actual load as per capacity)

8 Any other load of fractional H.P. (Not required)

Total
Details of the any other load, i.e. Industrial/AP/Bulk/PWW etc.

Sr. No. Details of Motors / Equipment BHP Load in KW Remarks, if any

List of documents to be attached with A&A Form (if required, Specimen of indemnity bond and resolution is available at SDO office) 
1. Copy of registration deed/ Municipal or Panchayat House – Tax Assessment Notice/ Allotment letter by HUDA/HSIDC/Housing Board/ Group Housing Societies/ Lease Deed/ 
Receipt of rent paid (Any one of the revenue document). 
2. Consent of landlord or Indemnity Bond, if consent of landlord not available, in case of tenant seeking connection 
3.  General power of attorney in favor of signatory, in case of joint ownership & partnership firms; Certified true copy of the resolution, authorizing the signatory to deal with the 
UHBVNL, passed by the Board of Directors, in case of companies (As & if applicable 
4. Self attested photocopy of the partnership deed in case of partnership firms / Memorandum & Article of association in case of companies (As & if applicable) 
5. Copy of layout plan of the factory premises showing proposed location of meter & metering equipment i.e. meter & metering equipment should be located in separate room 
at the main entrance of the factory premises having direct access from the main road. 
6. No objection certificate from Haryana water & Air pollution Control Board (if applicable). 
7. Attested copy of any one of documents listed in Sr. No. (8) of page‐1 of the Form. 
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DECLARATION

I [---------------------------------------------------------------------], son/daughter/wife of [-----------------------------------------------------------], resident of [-----------------------

------------------------------------------------], (hereinafter referred to as the “Applicant”, which term shall mean and include executors, administrators, heirs, successors

and assigns), do hereby swear and declare as under:

OR

The [-------------------------------------------------------------------------------------------], a company incorporated under the provisions of the companies Act – 1956, a sole

proprietorship, a partnership, a partnership having its registered office at [------------------------------------------------------------------------] (hereinafter referred to as

“Applicant”, which expression shall unless repugnant to the context or meaning thereof, include its successors and assigns), do hereby swear and declare as under:

1. THAT the applicant is a legal occupant / owner / landlord of the premises at [---------------------------------------------------------------------------------------------------
----------] in support of which the applicant has enclosed a proof of occupancy / owner ship. And,
2. THAT In case of tenant;
(i) The Written consent of the Landlord of the Applicant’s taking of the said supply is enclosed herewith. Or
(ii) The applicant is the lawful occupier of the premises, but has not been possible to obtain consent of landlord and the applicant hereby agrees to keep the supplier
indemnified and harmless against all claims made and actions and proceedings initiated by the landlord or any person claiming through or under him by reason
of the giving of electric connection by the supplier to the applicant. Indemnity bond duly executed on court paper of Rs. 15/- is attached. And,
3. THAT the applicant has requested the Uttar Haryana Bijli Vitran Nigam Ltd (UHBVNL)(hereinafter referred to as the “Supplier”) to provide a service
connection in the above-mentioned premises in the Applicant’s name for the purpose mentioned in the application & agreement form. And,
4. THAT the Applicant hereby further agrees and undertakes:
(i) The applicant desires to have and agrees to take Electrical supply for the purpose stated in the Application and Agreement form, from the supplier at the
premises stated, not exceeding the sanctioned load of the installation. And,
(ii) To indemnify the supplier against all proceedings, claims, demands, costs, damages, expenses that supplier may incur by reason of a fresh service connection to
the Applicant. And,
(iii) That all the electrical work done within its / their premises are as per the Indian Electricity Rules-1956, and indemnify supplier against any loss to the applicant
accrued on this account. Further, applicant agrees that if there is any harm / loss to the property of supplier, due to the fault of the electrical network within the
premises of the Applicant, all the liabilities shall have to be borne by the applicant. Further, that the lift installed (if applicable) has been inspected and certified
by the Lift Inspector and the all the fire safety norms have been complied with and the necessary fire clearance certificate (if applicable) has been issued by the
competent authority. The applicant indemnifies the supplier against all proceedings, claims, demands, costs, damages, and expenses that supplier may incur by
violation of the above regulations. And,
(iv) To accept and abide by all norms, Conditions of Supply, including Schedules of Tariffs, Schedule of General and Miscellaneous Charges, as per the provisions
of The Electricity Act-2003 and other applicable laws in force, Rules / Regulations / Orders / Directives / Notification issued and enforced under applicable
laws by HERC / CEA / Govt. of India / Govt. of Haryana and any other instructions / circulars issued by supplier / Nigam from time to time, and as amended
from time to time, for equitable and efficient distribution of electric energy. And,
(v) To pay for the said supply in accordance with the relevant applicable Schedule of tariffs and also to pay all such other proper charges (including MMC, if
applicable), as may become due, to the supplier, from time to time at rates laid down in the Standard Schedule of General & Miscellaneous Charges prescribed
by the supplier. And,
(vi) To pay taxes / duties, as may be levied on the sale of electricity to the applicant by the supplier. And,
(vii) Require the supplier to supply with the necessary meter/meters on hire in terms of the section-55of the Electricity Act-2003. The applicant agrees to give the
Supplier such Meter Security and Monthly Meter service Charges, as may be required for the price of the meter/meters, whenever called upon to do so. In case,
meter is not readily available, the applicant may be permitted to arrange own meter of standard specification as approved by the supplier. And,
(viii) To be responsible for the safe custody of the meters, CTs, PTs, Cables etc provided by supplier and in case there is any damage to these equipments due to
reasons attributable to the applicant, the same shall be chargeable to the Applicant. Further all repercussions, on account of breakage of seals of meters etc,
Direct / dishonest/ abstraction of energy shall be to the account of applicant as per the extant rules of supplier. And,
(ix) To allow clear and un-encumbered access to the meters for the purpose of meter reading and it’s checking. And,
(x) That the applicant shall have no objection at any time to the rights of the supplier to supply energy to any other consumer from the service line or apparatus
installed on the applicants premises. And,
(xi) That the supplier shall not be held responsible for any interruption / diminution of supply beyond its control. And,
(xii) That the supply shall be used for the purpose that it has been sanctioned by the supplier and shall not be misused in any way to serve any other purpose.
(xiii) That the supply shall not be extended/sublet to any other premises. And,
(xiv) That the Applicant’s industry/trade has not been declared to be obnoxious, hazardous/ pollutant by any Government agency and that no court orders are being
infringed by grant of applied electricity connection at the Applicant’s premises. And,
(xv) That grant of electricity connection will not confer any legal right for regularization of building/ land use in respect to the electricity connection provided at the
Applicant’s premises.
(xvi) That the supplier shall be at liberty to adjust the electricity consumption charges along with any other charges against the security deposits paid by the
Applicant, in the event of termination of agreement or in case of any contractual default.
(xvii) To pay any sum which may be found to become payable to Supplier with regards to all liabilities personally as well as by means of both movable and
immovable properties. And,
(xviii) To deposit additional consumption security / ACD as revised by UHBVNL from time to time as per the prevailing regulations of HERC. And,
(xix) That the supplier shall be at liberty to transfer the dues remaining unpaid by the applicant to other service connection (s) that may stand in the Applicants name
and recover the same against the Consumption security / ACD. And,
(xx) That the applicant would let supplier to disconnect the service connection under reference, in the event of any default, non-compliance of statutory provisions
and in the event of legally binding directive by a statuary authority(s)to effect such an order. This shall be without prejudiced to any other rights of supplier
including that of getting its payment as on the date of connection. And,
(xxi) The applicant is not a defaulter under the jurisdiction of UHBVN and DHBVN. And,
(xxii) There is no outstanding defaulting amount against the premises on which the connection is being sought. And,
(xxiii) To pay any sum which may be found to become payable to supplier with regards to past dues of supplier of the above premises. And,
(xxiv) That the applicant shall abide by the power cut, restricted/peak load hour’s restrictions imposed by the Supplier from time to time. And,
(xxv) All details furnished in this Application and Agreement forms are true to the Applicant’s knowledge. If any information is found incorrect / concealed at a later
stage, then the supplier will have the right to withhold / disconnect supply without any notice, as the case may be and forfeit the securities deposited with the
supplier and the supplier will have right to adjust all dues against the security deposits. And,

The Applicant further agrees that this declaration given by him will be construed as an agreement with the (UHBVNL) / Supplier to the above effect.

Witness Name ________________________

Father’s name ________________________ Signature of the Applicant __________________
Account Number _________________________
Signature __________________________
 
Name of the applicant ______________________

Applicable in case of company

-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Acknowledgement  
Applicant’s Name  Category of supply Receipt No. Date of Receipt
   

(Signature of authorized officer)