Chhattisgarh State Power Distribution Company Limited — Customer Care Service

Application Form for High Tension (HT) / EHT Service Connection

New Connection / Shifting of Premises / Change in Contract Demand / Change of Tariff Category / Change of Name of Consumer

(Please strike-off the purpose that is not applicable)

Application Reference No. (office use):

Date of Receipt:

To:

Request for supply

I / We request you to supply electricity to my / our premises. The requisite information is furnished below:

1. Consumer Information

(a) Name of the person / organization:

(b) Name of Father / Husband / Director / Partner / Trustee:

(c) Complete Address of the premises (new connection / shifting):

Pin Code:

Chhattisgarh State Power Distribution Company Limited — Customer Care Service

Contact Information

Factory / Premises:

Registered Office:

Residence:

E-mail:

Bank A/C No. (Optional):

2. Voltage at which supply is required (kV)

11 kV 33 kV 132 kV 220 kV

Select voltage:

(Please strike-off category not applicable and tick the category applicable)

3. Type of Supply

Select type:

If Temporary, specify period: From To

4. Steps taken by the consumer so far to set-up the installation

5. Basis of Projection of Contract Demand required

Diversity Factor assumed:

Total Connected Load:

6. Phasing of Contract Demand (CD)

S.No.	Contract Demand Required (kVA)	Tentative Date from which required	Remarks
1
2

Chhattisgarh State Power Distribution Company Limited — Customer Care Service

7. Purpose of Installation

8. Tariff Category Opted

Select tariff:

9. Production Capacity

10. Category of Industry

SSI (Small Scale Industry (includes Micro & Small)) / MSI(Medium Scale Industry) / LSI (Large Scale Industry)

Select category:

(Please strike-off category not applicable and tick the category applicable)

11. Status of Land Acquisition

12. Expected date by which Finance would be available

13. Consent / NOC from C.G. Environment Conservation Board (where applicable)

Chhattisgarh State Power Distribution Company Limited — Customer Care Service

14–16. Electricity Dues Outstanding

14. Any electricity dues outstanding in CSPDCL area of operation in the Consumer’s name: Yes / No

15. Any electricity dues outstanding for the premises for which connection applied for: Yes / No

16. Any electricity dues outstanding with the licensee against any firm with which the consumer is associated (Owner / Partner / Director / MD): Yes / No

(If ‘Yes’ for 15, 16 & 17, please provide details below)

17. Declaration

(a) The information provided above is true to my knowledge.
(b) I / We have read the Chhattisgarh Electricity Supply Code and agree to abide by its conditions.
(c) I / We will deposit electricity dues every month as per applicable tariff and charges.
(d) I / We will own responsibility of security and safety of the meter, cut-out and installation thereafter.

Date:

Place:

Signature of the Consumer / Authorised Signatory

Chhattisgarh State Power Distribution Company Limited — Customer Care Service

List of Attachments

The following documents shall be attached with the application form:

Proof of ownership of the premises.
Map indicating proposed location & supply point (scale 1 cm = 1200 cm).
Licence / NOC, if required; or declaration that NOC not required.
Affidavit (proprietary firm) — sole proprietor.
Partnership deed (partnership firm).
M&AoA + Certificate of Incorporation (Ltd. Co.).
Proof of permanent residential address & PAN (if any). Notify CSPDCL of changes immediately.
Letter of intent for production / enhancement.
List of equipments with expected load.
Resolution for authorized signatory.
Registration from Industries Department.
Extract of project report (power/process).
Tariff order section (opted category) duly signed; to be appended with agreement after formalities.