GOVERNMENT OF GOA ELECTRICITY DEPARTMENT [Form of reuisiion for Supply of Energy under the Elctcty Act, 2003) To, ‘Tho Executive/Assistant Engineer (Electrical), Etectrcity Department, Government of Goa, Division/Sub-Division + Goi Si, This requisition is for a new service/a sub-service trom an existing service (the name, address and installation number of the consumer whose service isto be tapped is to be stated herebolow/an extension {o my existing installation froma re-connection/a change of name/change of catagory of installation number 7 Wo hereby request you to give supply in accordance to Section 49" of tho Elacrcty Act, 2009 within {one month or within such period as may be specified by the Appropriate Commission to the premises owned’ Jocoupied by me/us and situated within the area of supply under your jurisdiction. We further require you to supply meus with the necessary rietor(s) on hire in terms of Section ‘55! Of the Electricty Act, 2003 and We agree to give you such security as may be required for the price of {he meter(s) and for supply of electrity as under Section ‘47" of the Electricity Act, 2003, whenever called "upon to do so. . ‘The details are stated herebelow 1. Applicant's NameAdcress (in block lotto): Applicant's telephone number sui Mobilo No, 2, Status of the applicant with respect to the premises lie. Owner/Occupiar/Authorised Person/Director] = 8. Description of the Pramises/Firm NoJName Street TownVilage . . District 4. Namo & Present Address of the Ovwnar [i the premises belongs to anothar person] : 5. The purpose of electricity (Domestic/CommercialAgrculture/industialPublic Water Works/ice Planvit) + For .. 2 6. The following are mylour requirements, Type of Load No. of Load” | Total Wattage ponts | waenva | WHPRKVA Ligat 60 W Fans : BOW ‘Ait conditioner Heating appliances Plug 5 Amps, cow Plug 15 Amps 500 W industrial power/ motovapparatus Others Toial 7 no