’ NOT FOR SALE- COSA ‘Surname/Company Name: First Na Middle Namo: ID/Passport No.: Country: PO.Box: Code | Town: Mobile: Office Tel: E-mail: = "County: District: Division: ® ‘Sub-Location: Street: Village Estate: Contact Person: | Sef ~_ g | _Gustomer Contact Person: Name Telephone EU aa RL County District: Division: Kenya Power © sien’ Street: Pict: [1 no: : urn: C] & Villagetestate: are é Business 2 LandmarkiRoute map/Site Direction POWER DATA New ‘Additional Load Account No Meter-Separation —_Re-routing ‘Type of Application Others: (Please specify) No. of Meters Required ie) Seldom La) ‘Customer Application Numi ‘ADMD. House NoName No. of Moters ‘Account Number Previous ADMD ‘See the back ofthe form fora lst of allowed types for each numbered data item and a box for helping you work out the ADMD ADMD: After Diversity Maximum DemandAPPLIANCES AND MACHINERY LIGHTING POINTS (Bulbs) No. PLUG POINTS (Socket outlets ) ‘Amp FIXED APPLIANCES (Cookers, Heaters, Air conditions idges, Ovens e-t.c) 1 2 3. a 5. 6 7 8 D._ MOTORS Purpose for which required No. Rating (HP or KVA) Phases 1 z 3. 4. 5 6 E. OTHER EQUIPMENT a = Note: Please attach a separate list if the above space is not adequate ‘Copy of national ID or Passport (non-Kenyans) or Certificate of Registration/Incorporation as appropriate. ‘Clear and detailed route sketch leading tothe premises where supply is required. ‘Sealed site plan (preferably in Softcopy) for Large Power Customers such as Industries, Housing Estates e.tc Applicants Name |. Signature. FOR OFFICIAL USE ONLY .. Date, Aiklath ed Roe eeu eT sr [Tio oe hs 6 ST [a i rl tan vonage, 1 KV [Ly tree pe ovens lite oan 36 aaa Co ten vote, 96 Toca can be estas ise 0 rota, 22017 [Ey wee ot anne Desai (eed