UTTAR HARYANA BIJLI VITRAN NIGAM LTD
APPLICATION & AGREEMENT FORM IN RESPECT OF DOMESTIC/ NON- DOMESTIC SUPPLY
(strike out whichever is not applicable)
(For Office use only)
(To be filed up by the applicant in Block letters in ink)
1. Applicant’s Name
2. Father’s name / Husband’s name
3. Full address of the premises at which supply is required.
4. Telephone No. (if any)
5. Permamnent Address (Residential)
6. Bank Account No. (if any)
7. Name of the Bank with address
8. Ration Card No./ Voter identity Card No./Pan
No. Driving License No.
Any
One
9. Details of any other connection
in the name of applicant (if any)
C ategory
Account No.
Address
10. Details of any other connection in the same premises ( if any)
11. If tenant, landlord’s Name & Address
12. Category of connection (DS or NDS)
13. Type of connection (Temporary or Premanent)
14. Connected Load / Contract Demand, applied for
( in KW/ KVA) ( Furnish details in table at page-4)
15. Voltage at which supply requires
(LT) 1 phase/ LT 3 phase/ 11 KV
16. Whether new connection , reconnection or extension/ reduction in load or change of name
17. Existing Account No.(if any) ( for reconnection, extension / reduction in load pr change of name)
Date:__________ Signature of applicant
Acknowledgement
Date Applicant’ Name Category of supply Application Nos._____________
(Signature of authorized officer)
Instruction for Applicants:-
(i) Application No. shall be allowed by the cashier at the time of receipt of Application processing charges.
(ii) Please furnish installation Test report issued by licensed electrical wiring contractor, after completion of installation giving full details of load/ machinery
Name of the Sub-Division
Application No. ________________________________
Date of Receipt ________________________________
________________________________
DECLARATION
I [-----------------------------], son/daughter/wife of [----------------------------------------], resident of [-----------------------------], (hereinafter referred to
as the “Applicant”, which term shall mean and include executors, administrators, heirs, successors and aasigness), do hereby swear and declare as under.
OR
The [--------------------------------------------------], a company incorporated under the provisions of the companies Act-1956, a sole proprietorchip, a
partnership, a partnership 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 assignees), do hereby swear and declare as under:
1. THAT the applicant is a legal occupant / owner / landlord of the premises at [---------------------------------------------------------------] in support of which the applicant has enclosed a proof of occupancy / owner ship. And,
2. THAT In case of tenant;
(i) The Written consent of the Landlord of the Applicant’s taking of the said supply is enclosed herewith. Or
(ii) The applicant is the lawful occupier of the premises, but has not been possible to obtain consent of landlord and the applicant hereby agrees to keep the supplier indemnified and harmless against all claims made and actions and proceedings initiated by the landlord or any person claiming through or under him by reason of the giving of electric connection by the supplier to the applicants. Indemnity bond duly executed on court paper of Rs. 15/- is attached. And,
3. That the applicant has requested the Uttar Haryana Bijli Vitran Nigam Ltd (UHBVN) (hereinafter referred to as the “Supplier”) to provide a service connection in the above-mentioned premises in the Applicant’s name for the purpose mentioned in the application & agreement form. And,
4. THAT the Applicant hereby further agrees and undertakes:
(i) The applicant desires to have and agrees to take Electrical Supply for the purpose stated in the Application and
Agreement form, from the supplier at the premises stated, not exceeding the sanctioned load of the installation. And, (ii) To indemnify the supplier against all proceedings, claims, demands, costs, damages, expenses that supplier may incur by reason of a fresh service connection to the Applicant. And,
(iii) That all the electrical work done within its / their premises are as per the provisions or Electricity Act 2003, and indemnify supplier against any loss to the applicant accrued on this account. Further, applicant agrees that if there is any harm / loss to the property of supplier, due to tha fault of the electrical network within the premises of the Applicant, all the liabilities shall have to be bome by the applicant Further, that the lift installed (if applicable) has been inspected and certified by the Lift Inspector and the all the fire safety norms have been complied with and the necessary fire clearance certificate (if applicable) has been issued by the competent authority. The applicant indemnifies the supplier against all proceedings, claims, demands, costs, damages, and expenses that supplier may incur by violation of the above regulations. And,
(iv) To accept and abide by all norms, Conditions of supply, including Schedules of Tariffs, Schedule of General and Miscellaneous Charges, as per the provisions of The Electricity Act-2003 and other applicable laws in force, Rules / Regulations / Orders / Directives / Notification issued and enforced under applicable laws by HERC / CEA /Govt. of India / Govt. of Haryana and any other instruction / circulars issued by suppliers / Nigam from time to time, and as amended from time to time, for equitable and efficient distribution of electric energy. And,
(v) To pay ffor the said supply in accordance will the relevant applicable Schedule of tariffs and also to pay all such other proper charges (including MMC, if applicable), as may become due, to the supplier, from time to time at rates laid down in the Standard Schedule of General & Miscellaneous Charges prescribed by the supplier. And,
(vi) To pay taxes / duties as may be levied on the sale of electricity to the applicant by the supplier. And,
(vii) Require the supplier to supply with the necessary meter/meters on hire in terms of the section-55 of the Electricity Act-2003. The applicant agrees to give the Supplier such Meter Security and Monthly meter service Charges, as may be required for the price of the meter/meters, whenever called upon to do so. In case, meter is not readily available, the applicant may be permitted to arrange own meter of standard specification as approved by the supplier. And,
(viii) To be responsible for the safe custody of the meters, CTs, PTs, Cables etc provided by supplier and in case there is any damage to these equipments due to reasons attributable to the applicant, the same shall be chargeable to the Applicant. Further all repercussions, on account of breakage of seals of meter etc, Direct / dishonest / abstraction of energy shall be to the account of applicant as per the extant rules of supplier. And,
(ix) To allow clear and un-encumbered access to the meter for the purpose of meter reading and it’s checking. And,
(x) That the applicant shall have no objection at any time to the rights of the supplier to supply energy to any other
consumer from the service line or apparatus installed on the applicants premises. And,
(xi) That the supplier shall not be load responsible for any interruption / diminution of supply beyond its control. And,
(xii) That the supply shall be used for the purpose that it has been sanctioned by the supplier and shall not be misused in any way to serve any other purpose.
(xiii) That the supply shall not be expended/sublet to any other premises. And,
(xiv) That the Applicant’s industry/trade has not been declared to be obnoxious, hazardous / pollutant by any Government agency and that no court orders are being infringed by grant of applied electricity connector.Applicant premises. And,
(xv) That grant of electricity connection will not confer any legal right for regularization of building/land use in respect to the electricity connection provided at the Applicant’s premises.
(xvi) That the supplier shall be at liberty to adjust the electricity consumption charges along with any other charges against the security deposits paid by the Applicant, in the event of termination of agreement or in case of any contractual default.
(xvii) To pay any sum which may be found to become payable to Supplier with regards to all liabilities personally as well as by means of both movable properties. And,
(xviii) To deposit additional consumption security / ACD as revised by UHBVN from time to time as per the prevailing regulations of HERC. And,
(xix) That the supplier shall be at liberty to transfer the dues remaining unpaid by the applicant to other sevice connection (s) that may stand in the Applicants name and recover the same against consumption security / ACD. And,
(xx) That the applicant would let supplier to disconnect the service connection under reference, in the event of any default, non-compliance of statutory provisions and in the event of legally binding directive by a authority.
(xxi) The applicant is not a defaulter under the jurisdiction of UHBVN and DHBVN, And,
(xxii) There is no outstanding defaulting amount against the premises on which the connection is being sought. And,
(xxiii) To pay any sum which may be found to become payable to supplier with regards to past dues of supplier of the above premises. And,
(xxiv) That the applicant shall abide by the power cut, restricted /peak load hour’s restrictions imposed by the Supplier from time to time. And,
(xxv) All details furnished in this Application and Agreement forms are true to the Applicant’s knowledge. If any information is found incorrect / concealed at a later stage, thea the supplier will have the right to withhold/ disconnect supply without any notice, as the case may be and forfeit the securities deposited with the supplier will have right to adjust all dues against the security deposits. And,
The Applicant further aggress that this declaration given by him will be construed as an agreement
with the (UHBVN) / supplier to the above effect.
Witness
Name ________________ _____________________
Father’s name ________________ Signature of the Applicant
Address ________________
________________ _______________________
Account ________________ Name of the Applicant
Number ________________
Signature _________________ _______________________
List of documents to be attached with A&A Form ( if required, Specimen of indemnity bond and available at SDO Office)
5. Copy of registration deed/Municipal or Panchayat House- Tax Assessment Notice/Allotment letter by HUDA/HSIDC/ Housing Board/
Group Housing Societies/Lease Deed/Receipt of rent paid (Any one of the Document).
6. Consent of landlord or indemnity Bond if consent of landlord not available. In case of tenant seeking connection.
7. for NDS connection, General power of attorney ‘n favor of signatory, in case of joint ownership & partnership firms; Certified true copy of the resolution, authorizing the signatory to deal with the UHBVN, passed by the Board of Directors, in case of companies (as applicable)
8. for NDS connections, self attested photocopy of the partnership deed in case of partnership firms/Memorandum & article of article of association in case of companies (as applicable)
9. Attested copy of any one of documents listed at Sr. No.(8) of page-1 of the form UTTAR HARYANA BIJLI VITRAN NIGAM LTD
For office use only
Applicant No. : _______________________________________
Applicant Name : _______________________________________
Father’s Name : _______________________________________
PAYMENT MADE WITH APPLICATION
Accepted on behalf of the Uttar Haryana Bijli Vitran Nigam Ltd. for connected load of_________KW
at_______________voltage level under________________category connection.
Cashier to accept charges on account of the following:-
Date____________ Signature___________
Sr. No. Item* Amount (in Rs.)
1. Application Processing fee
2. Consumption Security
3. Meter security (if applicable)
4. Meter tedting fee (if applicable)
5. Applicable Service connection Charges
as per HERC Regulation / Orders.
6. Any other item.
Total
*Strike out which ever is not applicable.
Received Rs____________________________(Rupees___________________________________
Vide Receipt No._________________________Dated____________________________________
Name________________________________Designation_____________Signature_____________
CERTIFICATE OF SITE VERIFICATION
Certificate that I have personally verified the premises of the applicant at his site on which the supply
is required.
Name of 11 KV feeder___________________________________________________
Name of Distribution transformer___________________________________________
Name__________________________Desognation____________________Signature___________
Date___________

NO DUES CERTIFICATE
Certificate that nothing is due against this applicant or the premises
Name__________________________Designation____________________Signature___________
Date___________

AUTHORIZATION FOR CONNECTION
For office use only
Accepted and Sanctioned on behalf of the Uttar Haryana Bijli Vitran Nigam Ltd. for connected
load of_________KW at_______________voltage level for________________category connection.
Date____________ SDO ‘OP’
The following charges / additional charges, document and equipment for release of connection as per
site verification be accepted.
(A) Charges:-
(B) Document & Equipments
(i) Test report
(ii) Energy Meter (if applicable)
Date_______________ SDO ‘OP’
Received Rs._________________(Rupees_____________________________________________)
Vide Receipt No._____________________________Dated:_______________________________
Name______________________________________Designation__________Signature__________
Received Documents & Equipments_______________________________________________
Name______________________________________Designation__________Signature__________
The Account number allotted to applicant is_____________________________
The service connection order number is_________________________________
Name______________________________________Signature_____________Date______________
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DETAILS OF CALCULATION OF LOAD TO BE FILLED BY APPLICANT (Norms may be revised from time to time)
Sr. No. Particulars No. of Points Total Load (In KW) For office use only
1 Light Points (40 watt each)
2 Fan Points (60 watt each)
3 Wall socket (5 Amp) (6 sockets or part there of=40 watts)
4 Wall socket (15 A) (6 sockets or part there of =1KW)
5 Rose Outlets for light Point
(i) For DS:- 1 to 5 rose outlets (40 watts); 6 to 10 rose outlets (2*40 watts)
(ii) For NDS:- 40 watt for each rose outlet
6 Air Conditioners through wall socket (take actual load as per capacity)
7 Geysers through wall socket (take actual load as per capacity)
8 Any other motive load in H.P. Total