APPLICATION FOR For Office Use

Application No :
ELECTRICITY SUPPLY Service Request 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:
Salutation : MR. Given Title :
Name of Applicant : MOHD NASEM BIN MUHAMAD MyKad/ Passport : 850219-11-5103
SETEFARZI
Date of Birth : 19-Feb-1985 Mobile No : 011112266284
Next of Kin : SITI AISYAH BINTI SUHAIMI Next of Kin Phone No : 0126020826

DETAILS OF PREMISES:
a. Address of Premises : 69,JLN PP 8 TMN PINGGIRAN PUTRA-SEK 2,BDR PUTRA
PERMAI,47100,PUCHONG,SELANGOR
b. Status of Supply : CHANGE OF TENANCY
c. Premises Type : DOMESTIC
d. Premises Description : RESIDENCE: LINK HOUSE (> 1 STOREY)
e. Correspondence Address : 69,JLN PP 8 TMN PINGGIRAN PUTRA-SEK 2,BDR PUTRA
PERMAI,47100,PUCHONG,SELANGOR
f. Electricity Supply Start : 13-Nov-2020
Date

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, TNB’s 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 landlord’s 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 computer - generated document. No signature is required.

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 DECLARATION FORM
(OWNER OF THE PREMISES)

To :

Tenaga Nasional Berhad,

Pejabat Setiausaha Syarikat,
Tingkat 2, Ibu Pejabat
Tenaga Nasional Berhad,
No. 129, Jalan Bangsar,
59200 Kuala Lumpur.

*We/I MOHD NASEM BIN MUHAMAD SETEFARZI (*NRIC No./Passport No/Company No : 850219-11-5103) having registered/residential
address at 69,JLN PP 8 TMN PINGGIRAN PUTRA-SEK 2,BDR PUTRA PERMAI,47100,PUCHONG,SELANGOR hereby agree and undertake to
Tenaga Tenaga Nasional Berhad (Company Registration Number: 200866-W) a company incorporated in Malaysia under the Companies Act 2016 and
having its registered office at Pejabat Setiausaha Syarikat, Tingkat 2, Ibu Pejabat Tenaga Nasional Berhad, No. 129, Jalan Bangsar, 59200 Kuala
Lumpur, Malaysia (hereinafter referred to as “TNB”), as follows—
1. *We/I hereby declare and admit that I am the Registered Owner of the premises which is located at 69,JLN PP 8 TMN PINGGIRAN
PUTRA-SEK 2,BDR PUTRA PERMAI,47100,PUCHONG,SELANGOR (hereinafter referred to as “Premises”) and the previous owner
and/or TNB registered consumer has vacated the Premises.

2. *We/I hereby agree and undertake as follows—

a) if the declaration stated in Clause 1 above is found to be incorrect by TNB and/or it is disputed by any party(ies) or *We/I no longer
own such Premises, then TNB will terminate the electricity supply contract by giving not less than 24 hours written notice to the
Premises and electricity supply to the Premises will be disconnected without any further notice;

b) will not demand from TNB any loss incurred as a result of the disconnection of electricity supply by TNB in Clause2 (a) above;

c) to indemnify and/or hold harmless TNB of all cost, damages and losses which TNB may suffer or incur against any claim from any third
party arising out of the disconnection and termination of electricity supply by TNB;

d) will bear any loss and/or expense including the costs and legal fees of TNB in enforcing this declaration in court; and

e) this declaration has been voluntarily signed without any element of coercion, intimidation or encouragement from any party and I fully
aware and understand the implications of this declaration.
3. The clauses in this declaration are separate and distinct from one another and at any time if any or more of these clauses become invalid in
law, then such invalidity will not have any effect to the other clauses.

4. This declaration binds the respective heirs, executors, administrator, successor-in-the-title and representatives appointed by *us/me.

5. *We/I do acknowledge that the information provided is true and up to date whereby any false statement will amounting to an offence and may
cause *us/me to be prosecuted and liable to civil claim in court.

6. *We/I give my consent to TNB to process *our/my personal data (including disclosing *our/my personal data to any third party appointed by
TNB) according to the Personal Data Protection Act 2010 for the purpose of this declaration form and other matters connected therewith.

Note: This is a computer - generated document. No signature is required.

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