Annexure 1: Requisition for Supply of Energy
(Asper theProvisions of Condition 3)
The Exccutive Engineer (Elcctricaly/
Assistant Engincer (Elcctrical)/
/Omcer-in-charge/Sub-Scction,
Elcctricity Depart1ncnt,
Goverment of Goa,.
Division/Sub-Division
Goa.
Sir.
Phase/Three Phase-L.T./H.T. supply:
IWe hereby submit application for:- Single Reduction of Load
New Connection (Permanent) Additional Load
Change in Contract Demand Change of Name
New Connection (Temporary) From
Department Own
Energy Meter
Department Own
Meter box including MCB
owned/occupied by me/us and situated within the area of Goa
and request to supply energy to the premises
Electricity Department.
meter. I/We agree to give you such secuity
IWe further request you to supply me/us with the necessary
that may be required as per rules, whenever called upon to do so. I/We shall abide by the rules & regulations
amendments therein from time to time.
prescribed by JERC & Electricity Act, 2003 and
The details are as stated herebelow:
Applicant's Name/Address (Block letters):
Mobile No.:
Applicant's Telephone No.
Email address:
Status óf the applicant with respect to the premises
[i.e. Owner/Occupier/Authorized Person/Director]:
Description of the Premises/Firm:
No./Name:
Street: Town/Village: Taluka: District:
Name & present address of the Owner (if the premise belongs to another person)
The purpose of electricity [Domestic/Commercial/Agriculture/Industrial/Public Wate: Works/Ice Plant 1T/
/Street Light/Others (P1. specify)]: For use.
1. The following are my/our requirement of connected load:
Type of load No. of points Load in Watts/HP/KW Total Wattage HPKW
Light
Fans
Air-conditioner
Heating appliances
Plug point 5 amps
Plug point 15 amps
Industrial power/motors/apparatus
Others
Total
1. Total conncctcd load applicd for: Watts/Kilo WattsP
3. Level of supply voltage(low voltage/1 |kV/33KV/L1OkV kV:
4. The system of wiring will be:
5. The wiring work willbe carricd out by:
Wiring Contractor's Liccnce No.:
Name:
Address:
Yours faithfully,
(Applicant's dated signaturc)
Name of the Applicant
Datc: The day of 20
Notes: (1) Attested copies of relevant document/NOClclearances atttached. (Please bring originals
for verification).
a. Proof of ownership of premises or proof of occupancy [Registered deed (for lease/
Irental /transfer etc.));
b. Copy of Land Revenue receipt giving the Revenue Plot No. (in case of agriculture/
/iigation pumpset);
c. Permission of landlord along with proof of ownership (in case of tenancy);
d. Copy of last bill paid (for load cxtension/reduction/change of contract demand);
e. Partnership decd, authorization in the name of the applicant for signing the requisition form and
agreement (in case of Partnership Fim);
f. Memorandum and Articles of Association and Certificate of Incorporation together
with an authorization in the name of the applicant for signing the requisition form and agreement
along with permanent address (in case of a public or ; vate limited company).
2. The applicant is requested tofill in the blanks, strike out the clauscs which are not applicable & attach
relevant documents.
3. The Electricity Department shall not be bound to comply with any such requisition under Section 43' of
the Electricity Act, 2003 unless and untill the applicant abides by the terms stated herebelow:
(a) Within 15 (fifteen) days after serving of power availability notice in writing by the Electricity Department,
the applicant shall tender duly executed and binding agreement in prescribed by the Department 'to take
supply of electricity for 1(one)/2 (two) year(s) in case of L.T/H.T. consumers.
(b) If required by the Electricity Department so to do, pays to the Electricity Department the service
connection charges as may bc determincd by the Commission for the purpose of the supply upon the property
in respect of which the requisition is made.
4. In lieu of the contract referred to in Note 2(a) above, the Departmcnt is prcpared to accept a declaration
in the following from subject to deposit of any required security by the applicable:
Declaration
IWe hercby declare that /We desire to have and agree with the Electricitý Department to take supply
of energy for the purposes mentioned in the requisition for a period of not less than one year for LT
consumer and not less than two ycars for HT/EHT consumer from the date of commencement of the supply
as determined by the Electricity Department and to be bound to the provisions of the Electricity Act, 2003
and to pay the Electricity Department's charges, appropriate tariffs applicable to meus and conditions of
supply as are applicable from time to time and in force.
Affix here
one rupce fifty
paise self adhesive
stamp
Applicant's Signature
Govt. Ptg. Press, Panaji-Goa--3234/10,000--03/2013.
