(To be submitted in Duplicate) UTTAR PRADESH STATE ELECTRICITY BOARD Shakti Bhawan 14, Ashok Marg, Lucknow Application form of Electricity connection for Industrial use only 1. Name & Address of Applicant 2. Name of Proposed Unit with Address for Correspondence 3. Type of Unit / Firm (Viz. Ownership / Partnership / Private Ltd./Public Ltd./Society / Govt. Deptt / Govt Undertaking 4. Site Address of Proposed Unit/Firm (Where electricity connection is desired). a) Building / Plot / Industrial Unit No. b) Locality / Industrial / Estate or Area or Sector Post Office ............. District ......... Pin Code 5. Name of Institution developing Industrial Premises (e.g. UPSIDC / SELF / Industries Deptt. Etc.) 6. Possession Letter or No Objection Certificate issued by the institution (Copy Enclosed) No. Date 7. Size of Plot/Shed 8. Required Electricity load for new connection ................. H. P. / KVA 9. Required additional Electricity load Present Sanctioned Load No. & H.P. / KVA Required Additional Load H.P. / KVA Present Electricity Supply Volts Volts Whether existing supply is through an independent feeder Yes / No 10. Where the above unit ever operated at some other place? If yes, address of that place and details of electricity connection a) Sanctioned Load b) Service connection no. c) Arrears of payments (If any) 11. If these existed in the past any electricity connection in the premises where connection is being requested. If Yes, details of electricity connection a) Name of Unit b) Service Connection No. c) Arrears of payment (if any) 12. Purpose of Process for which Electricity Load is required 13. Nature of Process Continuous / Non - continuous 14.a) Registration No. from Deptt. of Industries, U.P. Govt. b) No Objection certificate number with date of Pollution control board. (Copy to be enclosed) 15. Name of the Agency Financing the Unit UPFC / PICUP/Banks / SELF 16. Proposed date from which production is likely to start 17. Is there any other industrial unit operating in the vicinity of applicant? If yes, please give name and address 18. Place, voltage ratio & capacity of the nearest electricity sub. station and its distance from the unit a) 33/11 KVA S/S b) 132 K.V. S/S 19. Name of Electricity Distribution Division / Office of UPSEB in whose Jurisdiction the unit shall fall. Electricity Distribution Division Date: (Signature with Office Seal/Designation) DECLARATION I/We hereby declare that all the information given by me/us as above are correct to the best of my knowledge and belief and no facts have been concealed by me/us. I/We also declare and agree that in case any of the above information is found to be false U. P. State Electricity Board shall have the right to deny electricity connection at the above premises or disconnect electricity connection even if given on the basis of the above information. Date ______________ Signature Name of Consumer/Applicant
