HT NEW SERVICE CONNECTION FORM

CONNECTION DETAILS
NAME OF PERSON/ORGANIZATION
REGISTRATION NO. OF ORGANIZATION
NAME OF FATHER/HUSBAND/DIRECTOR/PARTNER/TRUSTEE
CONNECTION TYPE:	PERMANENT TEMPORARY
SELECT CATEGORY
SELECT PURPOSE

FOR OTHER THAN PERMANENT SUPPLY,SPECIFY PERIOD : FROM

TO

ADDRESS DETAILS WHERE NEW CONNECTIONS IS BEING APPLIED FOR
HOUSE NO/PLOT NO/KHASRA NO
AREA/COLONY
CITY/TOWN/VILLAGE
PINCODE
MOBILE NO

REGISTERED OFFICE ADDRESS:
HOUSE NO/PLOT NO/KHASRA NO
AREA/COLONY
CITY/TOWN/VILLAGE
PINCODE
TELEPHONE NO
MOBILE NO

RESIDENCE ADDRESS: (If Registered Address and Residence Address are same)
HOUSE NO/PLOT NO/KHASRA NO
AREA/COLONY
CITY/TOWN/VILLAGE
PINCODE
TELEPHONE NO
MOBILE NO
EMAIL ADDRESS FOR COMMUNICATION

LOAD/CONNECTION DETAILS:
VOLTAGE AT WHICH SUPPLY REQUIRED
CONTRACT DEMAND APPLIED
CONNECTED LOAD APPLIED

SELECT DISTRIBUTION CENTER:
CIRCLE
DIVISION
DC

BANK NAME
BANK ACCOUNT NO
IFSC
PAN NO
GST IDENTIFICATION NO.

CATEGORY OF INDUSTRY
AREA TYPE
Probable date of production:

Whether required complete work from discom side	YES NO
Whether connection required in Phases	YES NO

ELECTRICITY DUES OUTSTANDING INFORMATION:
Any electricity dues outstanding in the licensee's area of operation in the consumer's name :	YES NO
Any electricity dues outstanding for the premises for which connection applied for :	YES NO
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	YES NO
Whether the boundary within which electricity shall be consumed is clearly shown in the Plan (Map) of the premises	YES NO

I/We hereby declare that -

The information provided in the form above is true to my knowledge.

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

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.

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

I/We enclose/upload all necessary documents as per the list with the application form.

Date : 2023-05-29