FORM NUMBER : 54894373984

LV/MV - Domestic (any load) OR

LV/MV - Commercial (Load less than 10 KVA/ 8.5 KW)
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 ]
Southern 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 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 0.30 KW for domestic purpose / extension of load of the existing service at my / our
premises having Consumer No. 08081065003 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. 08081065003

I / We am/are depositing herewith an earnest money of R 200 Please adjust the earnest money with the amount that will be
determined to be recoverable from me/us as reasonable expenditure under the regulations made under Section 46 of the Electricity
Act, 2003, for providing new connection(s) / expenditure for extension of load / expenditure for alteration of service and requisite
deposit(s) to be made by me/us under the applicable Regulations. After making such adjustments, if any amount still remains
outstanding, the same may be adjusted with my/our electricity consumption bill(s) or refunded to me/us.

I / We hereby inform you that I/we am/are the owner(s)/occupier(s) of the premises and I/we enclose copy of documents
establishing sufficient proof of my/our bonafide occupation of the premises (viz., Passport / Voter Identity Card/ Rent Bill/ Rent
Control Challan / Telephone Bill / Municipal or any other Tax Bill / any other document issued by any Ministry or Department of
Government showing his occupancy in the premises etc.) / ownership of the 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 in 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 131, N S C BOSE RD where
electricity is supplied by you and that there is no outstanding dues in respect of that service connection.
FORM NUMBER : 54894373984

The full address of my / our premises, which will be inspected by you for the aforesaid purpose, Telephone No. / important land
mark ( if any) and nearest pole no. ( if available) are given below.

Address: Important Landmark:

Flat no - 3, Block - 12
REGENT PARK HOUSING EST Nearest pole No. (if available) :
131, N S C BOSE RD
KOLKATA 700040 Yours faithfully,
SUBRATA DAS
Telephone No : 9831307094
Identification Type: Driving License , No : WB-202007145100
Witness (1) Name : ANTHONY JOSEPH
O/3, BECHARAM CHATTERJEE STREET, KOLKATA
Identification Type: Driving License , No : WB012010766790
Witness (2) Name : GOPAL PATRA
34 SUKANTA SARANI, KOLKATA
Identification Type: Driving License , No : WB0120070514026
Note:
1) Please strike out inapplicable items.
2) The printed list of purpose of supply as approved by the Commission from time to time will be available from the licensee.
3) Please mention and describe important landmarks in the vicinity, if any, to facilitate easy identification of the premises.
4) Please attach, if possible, a small sketch (not to scale) indicating the location of the premises.
5) Earnest money to be deposited along with the application for new connection:-
For LV & MV supply
(I) For industrial purpose - R 2000/-
(II) For commercial purpose above contract demand in 10 KVA or above - R 1000/-
(III) For purpose other than (I) & (II) above - R 200/-
6) Earnest money will be accepted through Banker's cheque or Draft of Cash only.

I / we understand that for online application in place of my / our signature(s) and signature(s) of witnesse(s), as appearing in this
form, my / our or the witnesses, Land lord, Unique Identification Nos of Voter Identity Card / Aadhaar card / Driving License /
Passport may be used. I/ we undertake that each of such Unique Identification Nos is genuine and I / we indemnify and keep the
Licensee indemnified against any claim etc arising out of using such Unique Identification Numbers in place of respective
signatures and or the statements made in the said form. I / we understand that in case there is any dispute in this regard and / or any
statement made in the application the supply will be liable to be disconnected.

TO BE FILLED IN BY APPLICANT :
APPLICANT'S NAME : SUBRATA DAS
ADDRESS : Flat no - 3, Block - 12
REGENT PARK HOUSING EST
131, N S C BOSE RD
KOLKATA 700040
TELEPHONE NO : 9831307094
 LV/MV - Domestic (any load) OR
LV/MV - Commercial (Load less than 10 KVA/ 8.5 KW)
(For Office Use Only)
Annexure A Form Number : 54894373984 Mains Reference Number : 01/05728/15
Request For (Tick the appropriate box):
New Connection New Meter Extension of Load Shifting / Alteration / Others
Street Pump
(where supply does (where supply (for existing Strengthening of (Pole / Pillar Box
Lighting House
not exist) exists) consumers) Service Shifting)

Adjacent / Extg Consumer No : 0 8 0 8 1 0 6 5 0 0 3 Meter No. : 5 1 3 7 2 9 5

(for new connection) (for existing consumer)

Supply Required at:

Flat No 3 Block No 1 2 Floor Number
Premises Number 1 3 1
Apt. Name/Shop No(if any) R E G E N T P A R K H O U S I N G E S T
N S C B O S E R D
Road/Street/Lane (2panel)
Town / City / District K O L K A T A
Pin Code 7 0 0 0 4 0
Lamp Post Number(for OH)

Status of Supply at The Above Premises:

No Supply AC HT
(Tick the appropriate box)
Please furnish your load requirement (New / Additional) Watts or KV in appropriate box below
Domestic .3
Commercial
(any load) (Load less than 10 KVA/ 8.5 KW)
Intention of Applicant to bear the Cost of Meter: YES NO (Please tick the appropriate box)
To Help us serve you better kindly furnish following information.
Applicant's Detail:
(Mr/Ms) M s Date of Birth 0 4 / 1 2 / 1 9 7 5
Name / S U B R A T A D A S
Organisation Name
Telephone Number : Mobile-1 9 8 3 1 3 0 7 0 9 4 Mobile-2 Land Line
E-mail id : c g c 1 @ r p - s g . i n

I/we hereby confirm that the information given in the Form is correct and true to my/our knowledge and I/we
understand that CESC Limited will rely upon such statement made by me/us.

SUBRATA DAS
DATE : 09/04/2015 Identification Type: Driving License , No : WB-202007145100

(THIS FORM IS SUBMITTED FROM 10.40.4.11)

 Way Leave Permission
( See Regulation 3.2.1)

FORM NUMBER : 54894373984 FORM-1

To
District Engineer,
Southern District,
CESC Limited
Sir,
I / We have no objection to allow the fixing and erection of the necessary apparatus on or within the premises at REGENT
PARK HOUSING EST 131, N S C BOSE RD KOLKATA 700040 owned by me / us, for effecting service connection to the premises at
Flat no - 3, Block - 12 REGENT PARK HOUSING EST 131, N S C BOSE RD KOLKATA 700040 owned / occupied by Sri / Smt / M/s SUBRATA
DAS son / daughter / wife of ....................................................................................................

I / We have no objection if the service line passes over / along / across / under premises at REGENT PARK HOUSING EST 131,
N S C BOSE RD KOLKATA 700040 owned by me / us for effecting service connection to the premises at Flat no - 3, Block - 12 REGENT
PARK HOUSING EST 131, N S C BOSE RD KOLKATA 700040 owned / occupied by Sri / Smt. / M/s. SUBRATA DAS son / daughter / wife of
....................................................................................................
Yours faithfully,
Name :
Identification Type :
No :
DATE : 09/04/2015
Location Guidance :

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