Doc No : COM-F-34

Application Form for Temporary Disconnection/Renewal of Rev No : 01

Temporary Disconnection
Eff. Date: 01.05.2019

Customer ID: 50000______________ Dated: ______________

Customer Name: _______________________________________________________________________

Address:_______________________________________________________________________________
______________________________________________________________________________________
___________________________________________________________________________________

Contact No: (R) ________________ (M) ____________________Email ID: _________________________

Meter Reading at the time of Request:

Dear Sir,

I / We herewith request Gujarat Gas Ltd. to execute following work at our above mentioned address.

Sr. No. Particular Amount Select the

request
(/ x)
1 Temporary Disconnection
2 Renewal of Temporary Disconnection
3 Re-connection Request

Options for Temporary Disconnection:

Sr. No. Particular Amount Choose the

(excl. Taxes) option
(/ x)
1 TD for up to 270 days Rs. 350/-
2 TD for up to 365 days Rs. 475/-
3 TD for up to 540 days Rs. 700/-
4 TD for up to 730 days Rs. 950/-
I have noted the conditions stated herein, and abide to the same,

(A) Temporary Disconnection (“TD”) will be applicable for opted period only. Customer has to renew the
TD on or before the period expiry by paying the requisite charges as per the Tariff Card. TD period
shall never exceed more than 730 days.
(B) Customer to remain present at site to ensure the disconnection at the site
(C) Actual charges will be applicable as mentioned in the Tariff Card
(D) Before disconnection procedure customers are requested to make all the outstanding amount
including Temporary disconnection/reconnection, interim bill generated & full payment of balanced
connection EMI charges.

Note* please note that payments paid by CTS Cheque / DD in favour of “Gujarat Gas Ltd.” (Non-MICR & POST DATED Cheque shall not be
accepted).

Further, I understand that Gujarat Gas Limited has to perform an Annual Maintenance, at least once in a
year and as the TD request submitted herein exceeds, (for cases of TD request >365 days in one request
or cumulative by way of TD extension request) 365 days, than under the circumstance of house being not
available, the undersigned customer hereby waives the requirement of conducting the Annual
Maintenance and absolves GGL and its associates of any liabilities arising out of the asset installed by
GGL for supply of Piped Natural Gas to the premises as referenced in the customer number mentioned,
thereof.

I, would alternatively request GGL to accept our request on chargeable basis, at extra cost to service and
carry out Annual Maintenance – as out of turn once we revoke the TD and the premise is made available.

Customer’s Signature:_________________

For office use only

Customer ID: 50000______________ By Cheque/DD/ Tx Amount:

_______________________

Customer Name: ________________________________Cheque/ DD/ Tx No.:______________________

Bank Name: ________________________________ Cheque/DD/ Tx Date:

_____________________

Payment request towards: _______________________________________________________________

--------------------------------------------------------------------------------------------------------------------------------

Customer Copy Dated: ___/___/_____

Customer ID: 50000______________ By Cheque/DD Amount: _______________________

Bank Name: ________________________________ Cheque/DD/ Tx Date: _____________________

Payment request towards: _______________________________________________________________