JHARKHANDBIJLI VITRAN NIGAM LTD.

Application- New Connection (Low Tension Service)

Application fee receipt No.

Photograph of the
Date applicant with
signature
Application No.

To
THE ASSISTANT ELECTRICAL ENGINEER
ELECTAIC 'sUPPLY SUB-DIVISION

|Naneof the Appicart/ Organization :

2. Name of fatherhusband/Director/ Partner/ Trustee:

3. AddresS

For Communication House/PlotPremise No.

Street

Area/ Colony

District

Telephone No.:

House/Plo/Premise No.
b Where the new conncton is
Street
applied for / existing connection
is required to be shited.
Area/Colony

District

Telephöne No.:

(Indicate landmark to identfy he localion)

 .sq. feet
Covered area..
4.Plot slze: .... ..., sq.ft.

5.Category of Supply:
LIst of categorles attached)
6 Purpose of Supply

7 Total Load appled for In Kw):

Type of Supply
8 (Permanen/ Temporary): TFrom Date

If Temporary supply speclty To Date

8a. perlod of requirement
want to carry
Please Indlcate whether your
service lIne and/
out the works of laying faclty for the
distributlon
9 or dedlcated (yes/No)
electricity supply requisitloned
want to install
Please Indicate whether you
meter (Yes/No)
10. your own (CEA approved
attached:
11.'List of document &
submitted
(a). ldentity Proof application form.
with this card (W) Passport
along (0) Electoral identity
Licences (v) RationCard
(Gili) Driving Government agency
If Applicant is a person (v) Photo ldentity card
issue by
pradhan/
(tick any one) PAN card (vi) Certificate from village chowkidar,
(vi) worker/village
Patwari/Lekhapal village level centre etc.
charge of primary health
Primary School teacher/ in Branch Manager
authority (e.g.
Signature of competent relevant
etc) along with
Engineer
organization Principal Executive institutlon concerned
If Applicant is an resolution/authority letter of the
(tick any one) deed or in the care
ne of
Copy of sale deed or lease Khatian/ Khata Nakal
) khasra/
connections a copy of
agricultural
Attorney
(b). General Power of
occupancy of (i) Registered
Proof of ownership of
electricity allotment premises shall
Permises for watch (i) Letter of owner but an of the
who is not an
connection is required (v) An applicant (iv) above also
the documents listed at () to
any one of permises
(tick any one) along with the
certificate from owner of
furnish a no objection
(i) Passport
identity card
(() Electoral (iv) Ration Card
(li) Driving License Government agency
Proof of current address card issued by any
(c). (tick any one) (v) Photo identity running Bank Account
of Blls
(vi) Statement Electricity/ Gas Connection
Telephone/
(vil) Water/ assessment orders
(vil) Income Tax

specify)
applicable (Please
(d). Any other document as Yes/No)
consumer's name
are"S of operation in
outstanding in licensee's YesNo
Any electricitydues which connection applied for
12. premises for
for the
electricity dues outstanding
Any with whieh ha
13. ticensee against any firm
Distribut on Yes/No.
outstanding with the Managing Director
electrlclty dues Partner, Dlrec r or
Owner,
14. Any assoclated as on provide details on
consult 's In iny case please
answer ls Yes'
&15 7the
(Eor ues ons 13,14
a sepra Sheet)
 /We hereby doclare that
(a) The Informatton provlded in.thls appllcatlon is true to my knowlodgg
(b) I/we havo read the. .Eloctlrclty supply codo and agreg to abide by
tho conditlons mentloned thorein
(C) l/we wlldepost dues. every month as per the applicable oloctricity tariff and other charges
(d)
We will own the rosponsibllty of socurlty and satoty of the meter, out-out and the installatloin
thereater

Date

Place
Signature of the consumer/Authorised Signatory
Name
Note: Apart from documents for identlty proof. proof of ownershlp/occupancy of premises and proof of current
address the following documents shall be attached with the application form. In case of partnership firm- The
applicant shall furnlsh the partnership deed and an authorizatlon In the name of the applicant for signing the
requisitlon form and agreement
In case of publlc and/ or Private limited company The appllcant shall furnish memorandum and articles of
association and Certificate of Incorporatlon along with an authorlzation in name of the applicant for signing the
requlsition form and agreement.
Other documents appllcable only for select consumer categorles;
(a) Industrial consumers Valid Industrial lcense if appllcable
(b) Agricultural consumers: No objection certificate from competent government authority for tube wells if
required
(c) Non- Domestic Khokhas and Temporay Structure No objection Certificate for khokhas or temporary
structure form the Nagar Palike/Nagar Panchayat/ Gram Shabdha / Gram panchayat Land development
authority/ land Owningagency.
Annexure 3
Declaratlon/Undertaking
Son/Daughter of Resident of
(hereinafter referred to as "Applicant which term shall mean and include exclude executors
admínistrators. heirs, successors and assirns). do heretby swear and declare as under:
Or
The
a company incorporated under the provisions of the Companies Act, 1956 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 herby swear and declare as under:
THAT the Applicant is a lawful occupant of the premises at in support of
which the Applicant has enclosed a proof of occupancy.
THAT the Applicant has requested the Distribution Licensee to provide a service connection at the above-mentioned
premises in the Applicants name for the purpose mentioned in the application form.
THAT in furnishing the Declaration. the Applicant has clearly understood that should the above statements prove to be
false or incorrect at any later stage. the'Distribution Licensee shall have every right to disconnect supply to the
Applicant without any notice and above right to adjust docs against Consumer Security Deposit.
THAT the Applicant hereby agrees and undertakes:
1. To indemnify the Distribution Licensee against all proceeds dings, claims, demands, costs, damages, expnses that
he licensee may incur by reason of afresh sevice connection given to the Applicant.
2. That all Electrlcal works done within the premlses are as per Central Electricity Authority (Measures relating to
Safety and Electrlcity Supply) Regulatlons. 2010 and have been carried out be a llcensed electrical contractor (in case
the Appljcant ls.an owner adn wirlng in the premlsos In new)
 Or

relating to Safety and.

That all Electricat Work done wthln the premise are as oer Central Electrlcty Authority (Measures
reconnecting or Applicánt is
Electriclty Supply) Regulations. 2010 to the best of our Knowledae (where appllcatlon is for
occupler of the premises)
3 The Distributlon Licensee is indemnied agalnst any loss accruato the appllcant on this accout. Further, Appllcant
Llcensee's Tarift Schelule
To pay the electricity consumptlon blls and all other charoes the reacts set out in the Distributlon
and miscellaneous chargos for supply as may bc In force from tlrme to tlme. regularty as and when the same

5
To deposit the additional consumptlon depoat as revised by the Distrbutlon Llcensee from time to time based on the
consuinplion of the Applicatlon In preceding vear.
6. Toabide by the provislons of the Electrlcity Act. 2003 Electrlcityy Supply Code. tarif orders and any other rules or
regulations notfied by the Commisslon, as appllcable from timeto tlme.
7 That licensee shallbe at liberty to adjust the electricity consumption charges along with any other charges against the Consumer
Securlty Deposit paid by the Appllcant, In the event of terninatlon of the agreement prlor to expiry of the contracted period or in
case of nay contractual default.
8 "To be responsible tor safe custody of Meters. CTs. Cables eto. provided bythe Dlstrlbutlon Licensee and in case, there is Any
damage to equipment due to the roasons attributable to Appllcant the same shall be chargeable to the Applicant. Further, all
repercusslons on aCCount of breakage of seals of meters etc, or Direct/Dishonest Abstractlon of energy shall be to the account
of Applicant. as per the exlsting laws.

Acknowledgement

(name of appllcant) for

Applicatilon of
..purpoe) la hereby recelved on.... .... (date).
In this regard, the appllcant le gve a reference no......obe uBed for all uture correspondence.

Signature/ Seal of licensee's rapresentatlve

Name and Designatlon: