Assel- Asrar Khan

,Llsy fo|qr forj

,Llsy fo|qr forj.k lkxj izk-fy-ESSEL 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 PARTICULARSfuosnu -

dk;kZy; iz;ksx gsrqREQUEST NO.

(OFFICE USE)vkosnu/APPLICATION FOR

u;k dusDku

vfrfjDr Hkkj yksM

uke ifjorZu@lq/kkj

New Connection

ADDITIONAL LOAD

NAME CHANGE/CORRECTIONekax

Hkkj dh deh

lafonk ekax dk ifjorZu

DAMAND

REDUCTION OF LOAD

CHANGE OF CONTRACT DEMAND

fuEunkc

Js.kh ifjorZu

irs esa lq/kkj

LT

CATEGORY CHANGE

ADDRESS CORRECTION

mPpnkc

HT

miHkksDrk ekad@CONSUMER NO.:

[kaM 1-@SECTION 1. {ks= dk izdkj ykxw ij lgh dk fu'kku yxk,a @ Type of Area (tick one that applies)

?kjsyw

xSj ?kjsyw

ch-ih-,y-

DOMESTIC

COMMERCIAL

B.P.L.

gkWVsy

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

; dì;k fy[ksa------

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/kuJh Jherhdq-MkW-daiuh

vU; dì;k fy[ksa-------

Title Mr.Mrs.Ms.Dr.M/s

Others (Please specify.......)izFkee/;vafre

2-ciq:"k L=h

tUe frfFk

fn fn e e o o

vk;q o"kksZa esa2b.MaleFemale

Date of Birth D D M M Y Y

Age (in years)

firk@ifr dk uke

Fathers/ Husbands nameizFkee/;vafre

fekW dk uke Mothers Maiden Name izFkee/;vafre

2 l-vfrfjDr fooj.k laLFkku gsrq ykxw

Additional Details (Applicable for Organisation)

vf/kd`r gLrk{kfjrh dk uke Name of Authorized Signatory izFkee/;vafre

gLrk{kfjrh dk uke Designation of Signatory izFkee/;vafre

laLFkk dk izdkj fuxeu Type of Organisation fuxeu frfFk Date of Incorporation fnfneeoo

2 n-ifjlj dk izdkj ykxw ij fu'kku yxk,a

Type of Premises (tick one that applies)

Lo;a ds LokfeRo esa

fdjk;s@is ij

daiuh iznk

ljdkj iznk

vU;

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


xyh @ {ks=

Street/ Area

ySMekdZ

Lanedmark

kgj

City

nwjHkkk dz

Phone NO.

bZesy Email Id



vkidh csgrj lsok esa gesa lg;ksx ds fy, dì;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 LoadHkkj tqMko @ Load AdditionHkkj ?kVko @ Load Reductionvkosfnr 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 ukeizFkee/;vafre

firk@ ifr dk uke Father / Husbands Name izFkee/;vafre

uke ifjorZu@For Name changedkuwuh okfjl izdj.k

foh@[kjhn izdj.k

Legal Heir case

Sale/Purchase case

[kaM8-@SECTION8. irk lq/kkj@Address to be provided along with property proof/ownership details

?kj dz@ Hkou dk uke


xyh @ {ks=

Street/ Area

ySMekdZ

Lanedmark

kgj

City

nwjHkkk dz

Phone NO.

bZesy Email Id



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 set-up the installation: 1-/i.

2-/ii.

3-/iii.

4-/iv.

9l-/9c. 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 / Phasing of contract demand: ekad/S.No. vko';d lafonk ekax ds -oh-,- /CD Required(KVA) laHkkfor fnukad tc ls vko';drk gS/Tentative Date from Which required fVIi.kh@Remarks

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 gS-

10d.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* gks rks i;k fooj.k nsa

(For serial nos. 9b, 9c & 9d if answer is 'Yes' in any case please provide details)[kaM11/SECTION 11. ?kks"k.kk/Declaration

eSa@ge ;s ?kks"k.kk djrk gw@djrs gSa fd@I/We hereby declare that-

v 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.

ceSa@ge us e/; izns'k fo|qr iznk; lafgrk ds fo"k;&oLrq dks i

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Assel- Asrar Khan