MAHARASHTRA AIRPORT DEVELOPMENT COMPANY LTD.

Central Facility Building, B-Wing (North) 1st Floor, MIHAN SEZ, Khapri (Rly), Nagpur – 441108
Tel: +91-7104-665665, Fax: +91-7104-665600
• Email: jmd@madcindia.org, Website: www.madcindia.org
fo|qr iqjoBk tksM.kh vtZ ,&1 ¼vkS|ksfxd½
Power Supply Application Form A-I (Industrial)
uohu tksM.kh New Connection xzkgd Ø- ---------------------------------- ¼uohu tksM.kh uftdP;k xzkgdkpk@ vfrfjDr Hkkj vlY;kl Lor%pk½
vfrfjDr Hkkj Additional Load Consumer No. (Neighbour’s for New Connection / Self for Additional Load)
¼vfrfjDr HkkjklkkBh vtZ vlY;kl QDr , ¼1½ o c gs rDrs Hkj.;kr ;kos-½ (In case of Additional Load only Table A (1) & B are required to be filled)

egkjk"Vª fo|qr fu;ked vk;ksx ¼fo|qr iqjoBk lafgrk vkf.k iqjoB;kP;k brj vVh½ Subject to the provisions of MERC Electricity Supply Code
fofu;e & 2005 e/khy d`rhph ekuds fo"k;hP;k brj 'krhZP;k v/khu jkgwu- & other Conditions of Supply & SOP Regulation, 2005.

[kkyh ueqn dsysY;k tkxsojhy uohu tksM.khP;k fo|qr iqjoB;klkBh @ vfrfjDrHkkjklkBh eh @ vkEgh vtZ djr vkgs @ vkgksr-
I/we hereby submit this application for New connection/Additional load for supply of electrical rnergy at the premises mentioned below.

fVIi.kh%& d`i;k ;ksX; i;kZ;koj v’kh [kw.k djk o ykxw ulysys 'kCn [kksMk- Note: Please tick Appropriate box and strike off which is not applicable.

A. ,-½ vtZnkj o tkxspk rif’ky [kkyhyizek.ks Details of Applicant and Premises {*- vko’;d jdkus Mandatory Fields}
1) * vtZnkjkps uko ¼BGd v{kjkr½ ¼vksG[ki=kizek.ks½ uko First name oMhykaps@irhps uko Name of Father/Husband vkMukao Surname
Applicant’s Name (IN BLOCK LETTERS)
(As per the proof of identity) OR/AND
1) * laLFksps @ daiuhps uko ¼BGd v{kjkr½ Firm/
Company’s Name (IN BLOCK LETTERS)
2) T;k tkxh oht iqjoBk djko;kP;k vkgs- R;k tkxspk iRrk ¼d`i;k iw.kZ ri’khy |kok & dehr deh iR;kpk iqjkok Eg.kwu ns.;kr vkysY;k nLek,sotkizek.ks½ * Address of premises at which supply
is required (Please furnish complete details – Minimum as per the Address proof)
losZ Ø- Hkq[kaM Ø-
Survey No: Plot No.:
xYyh@jLrk @toGph [kw.k rkyqdk
Lane / Street/ Landmark: Taluka:
ftYgk fiu dksM Pin Code :
District:
3) bZesylkBh iRrk nwj/ouh Ø-% eksckbZy Ø-%
Email Id: Phone No.: Mobile No.
4) * tkxspk izdkj Lor%P;k ekydhph HkkM;kph izR;{k rkcsnkj @ brj ¼d`i;k Li"V djk½
Type of Premises Self Owned Rented Occupier / Other (Pl. Specify)

B. ch-
ch- fo|qr iqjoB;kph ekx.kh Power Supply Requirement
y?kqnkc flaxy Qst Fkzh Qst mPpnkc
LT Single Phase Three Phase HT

l/;kpk eatwj Hkkj @ekx.kh uohu @ ok<ho ekx.kh dsMCyw KW

dsMCyw KW dsMCyw KW ,dw.k Hkkj@ekx.kh
Existing sanctioned New / Additional
dsOgh, KVA dsOgh, KVA Total Load / Demand dsOgh, KVA
Load / Demand demand

C. lh- izfrosnu Declaration :

eh @ vkEgh vls tkghj djkrks dh%
• fo|qr dk;nk 2003 vkf.k egkjk"Vª fo|qr fu;ked vk;ksx ¼fo|qr iwjoBk lafgrk vkf.k
iqjoB;kP;k brj vVh½ fofue; 2005 e/khy izko/kkukaaps ikyu djhr @d#-
• l/;k T;k fBdk.kh fo|qr iqjoB;kph ekx.kh dsyh vkgs R;k fBdk.kh iwohZph Fkdckdh
vlY;kl v’kh Fkdckdh Hkj.ks eyk @ vkEgkyk ca/kudkjd vlsy o iwohZph Fkdckdh
vlY;kl eyk @ vkEgkyk uohu fo|qr iqjoBk feG.kkj ukgh- ;kckcr eyk@ vkEgkyk
voxr dj.;kr vkys vkgs-
• e-fo-fo-daiuhP;k izpfyr ohtnj i=dkuqlkj oht iqjoB;kP;k jdesP;k Hkj.kk djhu@d#-
• mijksDr fofu;ekuqlkj ns; gks.kkjs vU; vkdkj rlsp e-fo-fo-daiuhus eatqj dsysys ladh.kZ
vkdkj ;kapk Hkj.kk djhu@d#-
• mijksDr dk;nk o fofu;e ;kuqlkj e-fo-fo-daiuhyk ns; vlysY;k lqj{kk vuker jDdespk
Hkj.kk djhu@d#-
I/we make the following declaration; that I/we shall
• Abide by the provisions of the Electricity Act 2003 and Maharashtra
Electricity Regulatory Commission (Electricity Supply Code and other
conditions of Supply) Regulation 2005.
• Pay all electricity arrears (if any) of the premises for which I am / we are
availing the electric supply.
• Pay for the consumed electricity based on the prevailing tariff rates of
MADC .
• Pay for all other charges as they become due in accordance with above
regulation and approved schedule of charges of MADC.
• Deposit such security as MADC may be entitled to recover from me/us
under the above Act and Regulations.

lgdk;Z djk fot fcy osGsoj Hkjk ------------------ egkjk”Vª foekurG fodkl daiuh e;kZ-
 • e-fo-fo-daiuhus ekÖ;k @ vkeP;k tkxse/;s oht iqjoBk dj.;kl r;kj vlY;kph lqpuk
fnY;kiklwu ,d efgU;kP;k dkyko/khr lnj fo|qr iqjoBK ?ks.;kph geh ?ksrks vU;Fkk e-fo-fo-
daiuhyk ykxw vlysyk fLFkj oht vkdkj Hkj.;kph geh ?ksrks-
• ;k vtkZizek.ks fo|qr iqjoBk ?ks.kslkBh dk;|kus vko’;d vko’;d vlysY;k loZ ijokuX;k ek>sdMs
miyC/k vkgsr- eh vls opu nsrks dh- osGksosGh ykx.kkÚ;k loZ dk;ns’khj vko’;drsph iwrZrk
djsu- iw<s vls opu nsrks dh- ojhy dk;ns’khj ijokuX;k o vko’;drk fo"k;h tj dkgh okn
mifLFkr >kyk rj R;k cÌy e-fo-fo-daiuh tckcnkj jkg.kkj ukgh-
• vtZnkjkpk e`R;q >kY;kl ekÖ;k @ vkeP;k ukokoj tek vlsyyh lqj{kk vuker jDde vFkok
ckdh vlysyh f’kYyd jDde izkIr dj.;kdjhrk fdaok lek;ksftr dj.;kdjhrk eh @ vkEgh
[kkyhy O;Drhps ukefunsZ’ku djhr vkgs @ vkgksr-
Jh@Jherh -----------------------------------------------------------------------------------------------
• ojhy loZ ekfgrh [kjh vlqu R;kr dkgh pqdhph ekfgrh vk<GY;kl R;klkBh eh @ vkEgh
iw.kZr% tckcnkj jkghu@jkgw-
nk[ky dsysyh loZ dkxni=s eh riklysyh vkgsr-
All submitted documents are verified by me.
• Undertake to avail supply within one month from the date the MADC
intimates that it is ready to supply to our premises failing which I/we
undertake to pay MADC the fixed charges as may be applicable.
• Have obtained all required statutory permissions for availing an
electrical supply. I promise to fulfill all the statutory requirements from
time to time. I also undertake that MADC will not be responsible for
any issues arising due to non compliance (if any) of adhering to these
statutory permissions.
• In the event if death of individual I/We hereby nominate to receive or
adjust the deposit outstanding in my / our name to
Shri/Smt/ ________________________________________________
• The above information is true and if any false information is observed,
I/we will be fully responsible for the same.

¼e-fo-fo-daiuhP;k izfrfu/khps ukao] gqÌk o lgh½ vtZnkjkph lgh o fnukad

(Name Designation & Sign of Representative of MADC) Signature of Applicant & Date
D. Mh egRokph lqpuk Important Note:
bafM;u bysfDVªflVh #Yl 1956 P;k fu;e 45 vUo;s dks.kR;kgh xzkgdkP;k] ekydhP;k fdaok R;kP;korhus jkT; ljdkjus ijokuk fnysY;k ijokuk/kkjd bysfDVªdy dkWUVªDVj}kjs vkf.k ;ksX; ik=rsps izek.ki= vl.kkÚ;k O;DrhP;k
izR;{k ns[kjs[khf’kok; oht iqjoB;kps Lo#i vFkok {kerk@ Hkkj cnysy v’kk Lo#ikps fnos] ia[ks ¶;qt] fLop] deh OgksYVstoj pky.kkjh ?kjxqrh midj.ks o tksM.;k cny.;kph dkes osxG;k oht iqjoB;klanHkkZrhy ok<ho
dke] cny dj.ks] nq#Lrh vkf.k tqGo.kh dj.;kP;k dkekaP;k varHkkZoklg dks.krhgh fo|qr midj.ks bR;knh clo.;kps dke dj.;kr ;sÅ u;s-
Under Rule 45 of the Indian Electricity Rules, 1956, No electrical Installation work including additions alterations repair and adjustment to an existing
installation except such replacement of lamps, fans, fuses, switches, low voltage domestic appliances and fittings in no way alter its capacity of character
shall be carried out upon the premises of or on behalf of any consumer owner of occupier except by an electrical contractor licensed in this behalf ny the
State Government and under the direct supervision of person holding a certificate of Competency and by a person holding a permit issued of recognized by
the State Government.

E. b- tksMysyh dkxni=s ¼d`i;k ;sFks [kq.k djk½ Document Attached (Please Tick)
a. ,- iR;kpk iqjkok b. ch-
ch- ykx.kkjh brj dkxni=s c. lh-
lh- fo|qr iqjoBk tksM.;kiwohZ lknj djko;kph dkxni=s- Documents
Address Proof Other documents required requires before release of Electrical Connection

vko’;d dkxni=s egkjk"Vª iznq"k.k fu;a=.k eaMGkpk ukgjdr nk[kyk ¼ykxw vlY;kl½
1- y?kqnkc xzkgdkadjhrk (For LT consumers)
tkxk ekydkps uk&gjdr izek.ki= HkkMsdjkjklg ¼vtZnkj HkkMsd# NOC from MPCB (if applicable) • lap ekaaM.kh pkp.kh vgoky ¼izi= Mh&1½ Installation
vlY;kl½ fdaok rhu efgU;kph HkkMs ikorh Owners NOC lgh dj.;klkBh oS/k vlY;kps i= ¼laLFkk vFkok Hkkxhnkjh Test Report (D-1Form)
(if the applicant is tenant) Three month vlY;kl½ • dWiWlhVj pkp.kh vgoky Capacitor Test
house rent receipts. Authorization letter for signature on Certificate
[kkyhyhiSdh dks.krsgh dkxni=
(Any one of the following documents)
documents (in case of Company or
partnership).
2- QDr mPpnkc xzkgdkadjhrk (for HT consumers
Only)
LFkkfud izkf/kdj.kkph dj ikorh Local Authority daiuh LFkkiu djrkuk ns.;kr vkysys uksan.khd`r vf/kdkjh ;kaps
• Midj.kkph ekfgrh ,pih @ dsMCyq lfgr |koh- List of
Tax/Receipt izek.ki= Certificate of Incorporation from
Machinery with HP / KW
[kjsnh@foØh djkj Purchase / Sale Agreement Register of Company
daiuhP;k lapkyd@HkkxhnkjkaP;k iR;klg ukokaph ;knh] bZesy vkf.k • dsOgh, o deky ekx.khpk x.kd rDrk LVA MD
tehu ekyd@ jkg.kkj@lgdkjh laLFkscjkscj fodkldkus dsysyk
eksckbZy uaclZ- Calculation Sheet.
djkj Agreement with Land owner/Occupier
List of Directors/Partners alongwith their • lap ekaM.kh pkp.kh vgoky ¼izi= Mh&1½ Installation
/ Govt. Agency
'kklukus fnysys ekyeRrk dkMZ fdaok 7@12 mrkjk Govt. contact address, email & mobile numbers. test Report (1 form)
issued Property Card or 7/12 Extract ojhyiSdh dks.krhgh dkxni=s ulY;kl #- 200@& P;k eqqnzkadkoj • fo|qr fujh{kd ;kaph ijokuxh Permission from
tkxspk ekyd vFkok rkcsnkj vlY;kpk dks.krkgh ,d iqjkok izfrKki= n;kos ¼uequk&2layXu½ Electrical Inspector
Any document for proving owner or If any of the above document is not • okijsysY;k fo|qr lkfgR;kps pkp.kh vgoky
occupier of premises. available then affidavit on Rs. 200/- stamp Manufactures Test Certificate
paper should be submitted, (format-2 & VªkUlQkWeZj] bR;knh Transformer, etc.
enclosed)
fVIi.kh (Note):-
gk vtZ loZ vko’;d dkxni=klg rhu izrhr ¼,d ewG o nksu uDdy½ y?kqnkc lkBh vkf.k 5 izrhr ¼,d ewG o pkj uDdy½ mPpnkclkBh lknj dj.;kr ;kok (This form is to be submitted along with
all the required documents in triplicate (one original & two copies) for LT connections and in 5 sets (1 original & 4 copies for HT)
---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Ikksp ikorh
vtZ Ø-Ø- vtZ feGkY;kpk fnukad %
vtZnkjk
kjkps uko%
iRrk%
lgh o dk;k
dk;kZy;kpk f’kDdk
¼e-
¼e-fo-
fo-fo-
fo-daiuhps izfrfu/kh½

lgdk;Z djk fot fcy osGsoj Hkjk ------------------ egkjk”Vª foekurG fodkl daiuh e;kZ-