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Please Enter Application Number

Application Status :

(Fields marked * are mandatory)

Applicant Details

Application Number*

Application Date*

Applicant PhotoGraph

Applicant Signature

Connection Category*

DomesticNon-Domestic

Choose Category*

Note:- The Application shall rafer the applocable tariff schedule available on NDMC/DERC website for correctt tariff acategory. In case of any doubt, the application shall seek help of NDMC/DERC.

* based on funding pattern as per tariff sehedule.

Applicant Name*

(Max length 50 chars)

Name of Father/Husband/Director/Pratner/Trustee*

(Max length 50 chars)

Adress at which sullpay is required

House No*

(Max length 50 chars)

Street*

(Max length 100 chars)

Colony/Area*

(Max length 50 chars)

Pincode*

(Max length 6 chars)

Telephone Number

(Max length 8-12 chars)

Mobile Number*

(Max length 10 chars)

Email Address*

(Max length 50 chars)

Adress For Communication/Billing

House No*

(Max length 50 chars)

Street*

(Max length 100 chars)

Colony/Area*

(Max length 50 chars)

Pincode*

(Max length 6 chars)

Telephone Number

(Max length 8-12 chars)

Email*

(Max length 50 chars)

Please indicate whether you want to purchase your own CEA approved meter having additional features as approved by the Commission. YES/No.

YesNo

Nearest Landmark(Pole No./Feeder pillar No./Nearest House No.) to identify the location

Total Load applied for (In KW)/ (In KVA)

Purpose of Supply

List of Document Attached

Applicant is a PersonApplicant is an Organization

Declaration by the Applicant

I ----------- Son/Daughter of ---------------------- resident of (here in after referred tp as "Applicant". which term shall mean and include executors administrators, heirs,successors and assign), do hereby swear and declare as under:.

	That the applicant has requested the licensee to provide a service conncetion at the above mentioned premises in the Applicant's name for the purpose mentioned in the application form.
	That in furnishing the present Declareation, the Applicant has clearly unde