For Office Use :

APPLICATION FOR ELECTRICITY SUPPLY CA No.:

SR No.:

Please note that only submitted application with complete and correct information will be processed.

PART 1 : TO BE COMPLETED BY APPLICANT

For Application Under Individual Name :
Name of Applicant : RUZITA BINTI ABDULLAH MyKad / Pasport : 681018-02-5692
(Mr/Mrs/Ms) MADAM
("the Consumer")

Mother's Name : Date of Birth : 18-Oct-1968

(For Security Verification) (Below 18 years is not entitled to apply)

Next Of Kin : MUHAMAD SHAMIR BIN ABDUL ROHIM Next of Kin Phone No : +60104601504
(The person as an alternative to be contacted if we are unable to reach you)

Home/Office No. : Fax No. :

Mobile No. : +60135109490 Email : [email protected]

Communication Options: Letters Email Both

Billing Delivery Options: Byhand Post Email

(Please select one (1))

Details of Premises
a. Address of Premises : 12B ATAS, JLN TANAH MERAH TMN KIARA MAS, -, 06700 PENDANG, KEDAH
(where supply is required)

("the Premises")

b. Premises Ownership Owned Rented

c. Premises Type : Residential Use - Residence description :

(This activity will determine the (For example, Two storey terrace)
appropriate tariff)

Non-Residential Use Commercial Manufacturing Agriculture

Mining Streetlight

Main activity at premise: Commercial : Entertainment or Amusement

(For examples: Bakery Shop, Sawmill, etc.)

d. Correspondence Address : 12B ATAS, JLN TANAH MERAH TMN KIARA MAS, -, 06700 PENDANG, KEDAH
(If different from premises address above)

e. Supply required date : 15-Mar-2022 (Electricity supply by TNB is subject to consumers’ site readiness)

TYPE OF APPLICATION * Please select ( / )

New Electricity Supply (Permanent) Temporary Electricity Supply

Additional Electricity Supply Estimated Supply End Date :

Others : Supply Application - Existing Premises Change of Tariff (Do not fill section 2)

APPLICANT'S DECLARATION
1. I / We hereby attest that the contractor appointed by me / us / the housing developer as stated herein is a contractor registered with Energy Commission. I / We also give permission to the contractor
to do all necessary works related to my / our application.
2. I / We hereby attest that the electrical wiring is in a good condition.
3. I understand and agree that as the registered consumer for electricity at the said premise I will be liable for any electricity consumed during the tenancy and/or occupancy period including any loss or
damage suffered by TNB as permitted under the Electricity Supply Act.
4. I agree to ensure the meter, TNB’s installation and/or equipment at the said premises is not tempered at any time during the tenancy or occupancy period except with a written approval from TNB.
5. I / We hereby acknowledge that all information given are true and accurate and TNB shall have the right to take any necessary action if the information given are false or inaccurate.
6. I / We agree to all the Terms and Conditions of Supply as attached herein ("The Terms and Conditions of Supply for Consumer")and it shall become part of a binding
7. I / We as the signatory below do hereby consent to TNB, its agents and / or its permitted assigns for collecting, recording, holding or storing my / our personal data in accordance to Personal Data
Protection Act 2010 for a lawful purpose or necessary for any matters related to electricity supply by TNB.
8. I / We acknowledge that the telephone number / mailing address / e‐mail address provided is true and accurate and TNB will be notified if there is any change in the information. My / our failure to
update the telephone number / mailing address / e‐mail address will not cause the TNB to be liable for any failure to deliver the notices under this Contract.

Note: This is a computer - generated document. No signature is required.

Note: This is a draft document. Please check if your details are populated correctly. You may print this document for future reference.

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