APPLICATION FORM - AGRICULTURE PUMP CONNECTION

  
NAME OF PERSON*
NAME OF FATHER/HUSBAND *
APPLICANT CATEGORY :*
 
BANK NAME
BANK ACCOUNT NO
IFSC
PAN NO

ADDRESS DETAILS WHERE NEW CONNECTIONS IS BEING APPLIED FOR:

VILLAGE*
PATWARI HALKA NO*
BORDER AREA (HECTARE):
0 TO 2 HECTARE :
MORE THAN 2 HECTARE :

RESIDENCE ADDRESS:

HOUSE NO/PLOT NO/KHASRA NO*
AREA/COLONY*
CITY/TOWN/VILLAGE*
TEHSIL*
DISTRICT *
POST OFFICE*
PINCODE
TELEPHONE NO
MOBILE NO*
EMAIL ADDRESS FOR COMMUNICATION
ID PROOF :
ID PROOF DETAILS:*
AREA TYPE

LOAD DETAILS:
CONNECTED LOAD (In HP) *
IN CASE OF "CONVERT TEMPORARY TO PERMANENT PUMP CONNECTION" :
M. R. NO.
DATE

SELECT DISTRIBUTION CENTER:
CIRCLE*
DIVISION*
DC*
SELECT CONTRACTOR*


ELECTRICITY DUES OUTSTANDING INFORMATION:
Any electricity dues outstanding in the licensee's area of operation in the consumer's name :
Any electricity dues outstanding for the premises for which connection applied for :
Any electricity dues outstanding with the licensee against any firm/company with which the
consumer is associated as an Owner , Partner, Director or Managing Director

I/We hereby declare that -
  1. The information provided in the form above is true to my knowledge.

  2. I/We have read the Madhya Pradesh Electricity Supply Code as amended and
    agree to abide by the condition mentioned therein .Supply Code

  3. I/We will deposit electricity dues,every month ,as per the applicable electricity tariff and other charges.
    I am ready to pay applicable charges for new service connection.

  4. I/We will own the responsibility of security and safety of the meter , cut-out and the installation thereafter.

  5. I/We enclose/upload all necessary documents as per the list with the application form.
Date : 29-05-2023