LV/MV - Domestic / Commercial / Industrial

Application Form to be used by an intending consumer / a consumer requesting the licensee for an inspection of his
premises and preparation of estimate of expenditure to be borne by the intending consumer / consumer for new
connection / extension of load / alteration of service.
To: * Please delete the inapplicable portions.
District Engineer, [See Regulation 3.1 ]
West suburban District,
CESC Limited
Sir,
I / We hereby request for an inspection, of my / our premises address of which is given below, by your authorised representative, and preparation as also supply of an estimate by you to
me / us, giving in requisite details of the expenditures to be borne by me / us in terms of the regulations made by me / us in terms of regulations made under Section 46 of the Electricity
Act, 2003, together with the deposit(s) to be made by me / us in terms of the applicable Regulations for the purpose of getting new connection for supply of electricity at my / our premises
at MV / LV having an expected connected load of 1.00 KW for domestic / commercial / industrial purpose / extension of load of the existing service at my / our premises having
Consumer No. 11405114008 from ..........KW to ..........KW as estimated by my / our licensed electrical contractor / alteration of service, namely ........................................ (indicate the
nature of alteration of service) as indicated in the attached hand drawn sketch (attach hand drawn sketch if required) at my / our premises having Consumer No. 11405114008

I / We hereby inform you that I / we am/are the owner(s) / occupier(s) of the said premises and have documents establishing sufficient proof of my / our bonafide occupancy of the said
premises.

I / We hereby inform you that I / we intend to take meter on rental basis or by purchasing the meter through depositing the cost of the meter.

I / We hereby further declare that there is no other service connection / line live or disconnected, given / was given by you in my / our name (s) in the premises for which the new service
connection is being applied for.

1 / We hereby further declare that I / we have service connection in my / our name (s) in the premises at PARUI PACCA ROAD where electricity is supplied by you and that there is
no outstanding dues in respect of that service connection.

The full address of my / our premises, which will be inspected by you for the aforesaid purpose, is also mentioned in the Applicant's Information Form

Yours faithfully, Important Landmark:

ARCHANA MISHRA
Nearest pole No. (if available) :
Identification Type: Aadhaar Card , No : 936805817409
Address:
Flat no - 30/4B
BANK OF INDIA, PARUI PACCA ROAD
KOLKATA 700061

Telephone No: 9681057898

Note: 1) Please strike out inapplicable items. 2) The printed list of purpose of supply as approved by the Honorable Commission from time to time will be available from the licensee.
 (Annexure-A)

Request For (Tick the appropriate box): MR No. : 1 4 / 0 2 8 8 6 / 1 8

New Connection New Meter Extension of Load Shifting / Alteration / Others

Street Pump
(where supply does (where supply (for existing Strengthening of (Pole / Pillar Box
consumers) Lighting House
not exist) exists) Service Shifting)

Adjacent / Extg Consumer No :

(for new connection) (for existing consumer)
1 1 4 0 5 1 1 4 0 0 8 Meter No. : 3 0 2 9 1 2 7

Service MA Bill No. : / / (If applicable)

Supply Required at:
Flat No. 3 0 / 4 B Block No.
Floor No. Premises No.
Status of Supply Supply Not Existing Supply Existing
Apt. Name/Shop No. (if any) BANK OF INDIA
(Please the appropriate box) HT Supply Existing
P A R U I P A C C A R O A D
Road/Street/Lane (2Panel)

Road/Street/Lane (2Panel) KOLKATA Pin Code 7 0 0 0 6 1

Nearest Lamp Post No. (for OH)

Nature & Expected Connected Load Domestic 1 KW Commercial KW Industrial KW

Do you want to bear the cost of meter? (1 KW = 1000 Watts)
YES NO
(Please tick the appropriate box)
Help us to reach your premises by describing the location guidance with nearest landmarks:
Nearest Landmark NETAJI SANGHA CLUB Distance from Landmark 200 Metres
Colour of the House LIGHT ORANGE No of Storeys 0 Any other information (256 Char.)

Applicant's Detail: To Help us serve better kindly furnish following information

A R C H A N A M I S H R A
Name/Organization Name Mr / Ms

Date of Birth (DD/MM/YYYY) 0 5 / 0 4 / 1 9 6 9 Mobile -1 9 6 8 1 0 5 7 8 9 8

Mobile -2 9 0 0 7 1 9 7 8 8 5 Land Line

E-mail id v i v e k . m i s h r a 3 4 8 @ o u t l o o k . c o m
Alternate E-mail id o f f i c i a l @ l e g a l i g h t . i n
Account No. 401210310000101 Bank Name BANK OF INDIA
Branch Name LINDSAY STREET IFSC Code BKID0004012
WhatsApp No. 9681057898
Aadhaar Card Voter ID Card Identification
Unique Identification Type 936805817409
Driving License Passport No.
Way Leave Permission FORM-1
( See Regulation 3.2.1)
I / We have no objection to allow the fixing and erection of the necessary apparatus on / within the premises, owned by me / us for effecting services connection to the premises owned /
occupied by Sri / Smt / M/s ARCHANA MISHRA. Further, I / We have no objection if the line passes over / along / across / under the said premises for effecting the service
connection.
Unique Identification Details

Landlord Unique Aadhaar Card Voter ID Card Identification

Name
ARCHANA MISHRA Identification Type
936805817409
Driving License Passport No.
I / We undertake that my/our and the landlord's Unique Identification Nos. of Voter Id Card / Aadhaar Card / Driving Licence / Passport is / are genuine and I / we identify and keep the
Licensee indemnified against any claim etc. arising out of using such Unique identification Nos, and / or the statements made in this Form. I / we hereby confirm that the information given
in this Form is correct and true to my / our knowledge and I / we understand that CESC Limited will rely upon such statement make me / us.
I / We understand that in case any statement in this application is / are found to be false, the supply will liable to be disconnected.
 ARCHANA MISHRA
DATE : 16/01/2018 Identification Type: Aadhaar Card , No : 936805817409
 MR No. : 1 4 / 0 2 8 8 6 / 1 8

ROUGH SKETCH SHOWING LOCATION OF YOUR PREMISES, WITH PROMINENT LANDMARK, IF ANY.

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