APPLICATION FOR For Office Use

Application No : NC-000-160-4632
ELECTRICITY SUPPLY Service Request No :
Service Notification No :
Electricity Account No :
Please note that only submitted application with complete and correct information will be processed.
PART 1 : TO BE COMPLETED BY APPLICANT:
For Application Under Individual Name:
Given Title : MADAM
Name of Applicant : FADILLAH BINTI YAAKUB MyKad/ Passport : 841015-12-5938
Mother's Name : ROSNI BINTI HJ. MATASAN Date of Birth : 15-Oct-1984
Home/Office No : 078226587 Fax No : 078226587
Mobile No : 0128650550 Email Address : ferrarinaks84@gmail.com
Next of Kin : HAMIZI Next of Kin Phone No : 0197880159

DETAILS OF PREMISES:
a. Address of Premises : PTB 14428,NO 8,JALAN PERMATA 2/3,TAMAN PERMATA PENAWAR,81930 BANDAR
PENAWAR,JOHOR
b. Status of Supply : SUPPLY APPLICATION - EXISTING PREMISES
c. Premises Type : DOMESTIC
d. Correspondence : PTB 14428,NO 8,JALAN PERMATA 2/3,TAMAN PERMATA PENAWAR,81930 BANDAR
Address PENAWAR,JOHOR
e. Electricity Start Date : 13-Apr-2020

APPLICANT'S DECLARATION SECTION:

1. I / We hereby attest that the contractor appointed by me / us / the housing developer as stated herein is a contractor registered with Energy Commission. I /
We also give permission to the contractor to do all necessary works related to my / our application.
2. I / We hereby attest that the wiring is completed in all aspects and all electrical safety features have been completed as per standards prescribed by Energy
Commission.
3. I / We hereby agree to be bound by all terms and conditions relating to electricity supply of TNB as attached ("Terms and Conditions").
4. Tenanted or Occupied Premises
i. I understand and agree that as the registered consumer for electricity at the said premises I will be
liable for any electricity consumed during the tenancy and/or occupancy period including but not limited to any loss or damage suffered by TNB as
permitted under the ESA.
ii. I agree to ensure the meter, TNB͛s installation and or equipment at the said premises is not tempered at any time during the tenancy or occupancy period.
iii. I hereby agree to assist TNB to obtain the landlord͛s permission to connect the electricity supply to the said premises.
iv. I agree that the failure to obtain the consent of the landlord may delay the electricity supply connection to the said premises.
5. I / We hereby acknowledge that all information given are true and accurate and TNB shall have the right to take any action including but not limited to
disconnection of supply and/or termination of contract if the information given are false and inaccurate.
6. I / We as the signatory below do hereby consent to TNB, its agents and / or its permitted assigns for collecting, recording, holding or storing my / our personal
data or carrying out any operation or set of operations on my / our personal data within the meaning of the Personal Data Protection Act 2010 and Data
Protection & Privacy Policy including but not limited to any information, documents, records and accounts necessary for the performance of this contract.

Note: This is a draft document. Please check if your details are populated correctly. You may print this document for
future reference.

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