Madhyanchal Vidyut Vitran Nigam Limited

 
(U.P. Government Undertaking)
Head Office: 4-A Gokhle Marg,Lucknow -01

Application Form For Requisition Of Supply Of Energy

1. Name of the Applicant:….………………………………….. Affix latest

2. Father / Husband’s Name: ………………………………… Photograph of the
3. Occupation: ………………………………………………... applicant (Attested by
4. Address: Gazetted Officer /
(a) For Communication …………………………………... Bank Officer /Gram
………………………………………………………… Pradhan / Sabhasad)
…………………………………………………………  
Phone No:……………………………………………..
(b) Where Connection is required:……………………….
…………………………………………………………
…………………………………………………………
(Indicate land marks to identify the location)
Phone No:……………………………………………..
(c) Permanent Address:…………………………………..
………………………………………………………..
………………………………………………………..
Phone No:
5. Plot size............ sq.metres Covered Area................ sq. metres.
6. Total Load KW / KVA / HP:..................................................................
7. Purpose of Supply:..............................................................................
8. Details of Processing Fee:
(a) Amount ........................
(b) Mode - cheque / draft / cash
(c) No. .................. Date ......................
(d) Bank Name ........................................................................
(Following Information is to be furnished by Applicants Requesting Electric Supply
more than 50 KW and for Industrial Purposes)
9. Type of unit firm (viz: ownership: ............................................../ Partnership / Private
Ltd. / Public Ltd./ Society / Govt. Deptt. / Govt undertaking
10. Name of Institution developing Industrial Premises:.............................................. (e.g.
UPSIDC / self / industries deptt. etc.)
11. Possession Letter or No. Objection Certificate: ......................................................
issued by the Institution (copy enclosed.) No. ..................Date......................
12. Whether supply is needed through independent feeders:........................................
13. Whether the above unit ever operated at some other place or applied for connection?
(If yes, pl. furnish the following)
(a) Sanction load: ........................................
(b) Service Connection No. :..........................
(c) Arrears of payment (in any): ................................
(d) Address
14. If electricity connection for the premises is being requested in the past. If yes details
of electricity connection.
(a) Name of unit:........................
(b) Service connection no. :........................
(c) Arrears of payment (if any): ........................
15. Purpose or process for which Electricity load is required. :..............................
16. . Nature of process:..................................
17. (a) Registration No. from Deptt. Of Industries U.P. Govt. (Copy to be
enclosed) :............................

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(b) No objection certification from Pollution Control Board (Copy to be

enclosed.) ................
18. Name of the Agency Financing the unit (UPFC / PICUP / BANK / SELF / Any
other) :..................
19. Proposed date of start of Production: ....................................
20. Is there any other industrial unit operating in the vicinity If yes, please given name
and address............................................
21. Pl. specify voltage ratio & capacity of the nearest Electricity sub-station and its
distance from the unit: ......................................

Enclosures:
1. Work Completion Certificate and Test Report (B & L form)
2. Documentary evidence in support of lawful occupation of the premises. If the
applicant is not the owner of the premises, indemnity bond as specified by the
Licensee shall be enclosed.
3. Factory / Industry / Premises / Establishment / House map, where supply is desired,
indicating tentative position of the meter box.
4. Receipt for payment, if cash / cheque / draft.
5. In case of industry resolution of the Board of directors for authorising a person to sign
the document on behalf of the company.

Note 1. In case of consumers without MDI meter, the connected load can be 200% of the
contracted load in the domestic category and 133 % of the contracted load in the
commercial category
Note 2. In your own interest, please ensure permanent disconnection of your electric
supply, and obtain “No Dues Certificate” from Division before vacating the
premises
Note 3. Electric Connection shall not be treated as a proof of ownership of the Premises

DECLARATION

I /We.................................................................................... solemnly assure and undertake that

A. I / We hereby declare that I / we desire to have and agree with the Licensee to take a
supply of energy for the above mentioned purposes, for a period of not less than 2
years from the date of commencement of supply and to pay for the energy so supplied
and all other charges at the rates set out in the Tariff Order.

B. I / We also agree to be bound by the Licensee’s Distribution Code as approved by the

Commission including any modifications thereof and the provisions of Electricity Act,
2003 together with the Rules framed there under
C. I / We also declare that in the event of my / our failure to comply with the above
provisions, it shall be lawful for the Licensee to discontinue the supply in terms of the
aforesaid Distribution Code.
D I / We further declare that the Licensee shall not be held responsible for any
interruption /diminution of supply for reasons beyond its control.
E. I / We understand that this declaration can be cancelled after two years by either party
giving notice as per the procedure described in this code.
F. I / We further agree that this declaration given by me / us shall be construed as an
Agreement with the Licensee to the above effect.
G. I / We declare that all details furnished in the Application Form are true to my / our
knowledge. If any information is found incorrect at a later date, then the Licensee
shall have the right to withhold / disconnect supply, as the case may be.
H. It shall be ensured by me / us that there is no unauthorized addition / alteration to the
equipment or unauthorised use of electricity. In other words, it shall be ensured by me
us that the energy provided to me / us by the Licensee is utilized as per law and

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authorization. In case the Licensee has reasonable basis to understand or apprehend

that there is in any way whatsoever unauthorized addition / alteration to the
equipment or unauthorised use of electricity, it shall be open to the designated
authority of the Licensee to enter upon the premises for general inspection and testing
of the equipment, meter and wiring etc.
I. I / We undertake to intimate the Licensee as per the procedure described in the
Electricity Supply Code - 2005 whenever I intend to vacate the premises for which
the electric connection is being taken.

Date: ................................ Applicant’s Signature

Place:

(To be filled by the Licensee)

1. Date of application received:……………………………………

2. Contracted Load Sanctioned:……………………………………
3. Date of commencement of Supply:……………………………...
4. Consumer No / Connection No:…………………………………
5. Meter No:………………………………………………………...

Signature of Applicant Signature of Representative of the Licensee

Acknowledgement

Application form of Sh. / Smt. ......................................................, complete in all respects /

has following shortcomings, for requisition of supply is hereby received on .............................
In this connection, the applicant is given a reference No. .................. to be used in all future
correspondence.

Signature of Representative of the Licensee

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