PASCHIM GUJARAT VIJ COMPANY LIMITED
e-mail: info.pgvcl@gebmail.com Reg.Office: Paschim Gujarat Vij Seva
Sadan,Off.Nana Mava Main Road,Laxminagar, Rajkot - 360004 Web site:
www.pgvcl.com
Page 1 / 6
FORM OF REGISTRATION FOR NEW L.V. SUPPLY / ADDITIONAL L.V. SUPPLY / NAME CHANGE/
SHIFTING OF CONNECTION
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A1 FORM
Type Of Premises: slJH 5|:YF5GGM 5|SFZf
MSI, L - Industrial
Residential
Commercial
Industrial
Institution
Others
Agricultural
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To
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MAVADI ROAD S/D,
Punit Nagar,66 KV S/S,150 Feet Ring Road,Rajkot
Application No.
VZHLÊDF\S
The
Date
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24-04-2021
(Note Applicant is requested to to fill his / her name with all the details clearly and to sign )
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I/ We hereby request you to supply electrical for the premise owned / Occupied by
me / us . Details supported by necessary evidences are furnished hereunder.
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Details of Applicant: Full Name of Applicant:
MANSUKH NARSHI KOTHIYA
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( Begin with Surname )
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Legal Status of the Applicant:
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Appartment
Flat No.
Floor No.
V[5F8"D[g8
O,[8 G\P
DF/
Society
Plot No.
Sub-Plot No.
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34511
Page 2 / 6
Street
Mahollo
House No.
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Village
Others
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Res. Survey No.
City Survey No.
Ward No.
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T.P. Scheme No.
City
Pin Code No.
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Name of the occupier of the
land/premises
MANSUKH NARSHI KOTHIYA
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Evidence to be attached
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Transfer of Connection
No
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Name of the original consumer(if Yes)
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Purpose of the industry
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Consumer Service No.
30608204498
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(Copy of bill to be
attached)
This requisition is for the following purpose:
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New Connection
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Extension in Existing installation
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Name of the Consumer
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MANSUKH NARSHI
KOTHIYA
Reduction in Existing Installation
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Reconnection
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Page 3 / 6
Existing Sanctioned Load:
13.5 KW
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New/Addl. Demand GJL q JWFZFGF ,M0GL H~ZLIFT DF8[
Total(KVA):
38.833
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Total(HP):
Total(KW)
46.850
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34.950
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Details of the Load
Appliance Name
,F.84 5\BF VG[ VgI ;FWGM
AIR CONDITIONER(2TONNE)
Unit Value
I]lG8
Quantity
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Total
S],
2200 W
15
33000.000
REFRIGERATOR FULL SIZE 300 LT
300 W
1
300.000
COMPUTER - OLD OR 15 INCH
100 W
3
300.000
1/2 HORSE POWER WATER PUMP
375 W
1
375.000
9W
25
225.000
50 W
15
750.000
LED BULB
CEILING FAN 36" / 48"
Page 4 / 6
Present Postal Address of the applicant.
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Tel. Phone No.
Office / Factory No.
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Near by Consumer No.
Fax No.
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Details of the premises.
Name Change ( Necessary evidence to
be attached)
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Individual
Existing Consumer's Service No.
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30608204498
Industrial Complex
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Existing Consumer's Name.
MANSUKH NARSHI KOTHIYA
Residential Complex
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Residential & Commercial Complex
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Others
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Licensed Electrical Contractor
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License
Number
Telephone
Number
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Details of Licensed Electrical Contractor shall be furnished along with the application form.
However, in absence of the same, the Applicant may furnish the details subsequently on request of
Distribution Licensee.
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DECLARATION
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I/ We hereby declare that / We desire to have and agree with Distribution Licensee to take supply of energy
for the above mentioned purpose for period of not less then two years from the date of commencement of
the electrical energy and to be bound by the Distribution Licensee's appropriate tariffs, and charges and
condition of supply applicable to me / us as in force from time to time. I/We undersigned hereby state in
written that I/We demanded an electric connection in our Plot No…………….......... Flat No ……………......
Name of Society .................………………………………………………………. for the residential use /
commercial use on …………………………. date.
Earlier, there was no electric connection in aforesaid premises and any type of remaining dues regarding electric
connection in aforesaid premises. I/We responsible to pay any type of remaining dues regarding electric
connection in aforesaid premises if any, otherwise PASCHIM GUJARAT VIJ COMPANY LIMITED has the
Page 5 / 6
right to disconnect the aforesaid electric connection without giving any type of notice. I/We hereby bound
that I/We will not take any type of objection.
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VZHNFZGL ;CLP
Applicant's Signature
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Name & Signature of
Witness.
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In case of Thumb
Impression, signature &
Name of Witness is
necessary
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In case of Firm /
association power of
attorney holder signature
must be supported by
official seal.
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Cashier, Please accept.
Rs.__________
as Reg. Fee.
JE / DE
Registration Fee Rs.________________Paid
Vide Money Receipt No.____________ Date___________
Jr. Cl / Cashier.
Page 6 / 6
Note :
1. It is requested to fill complete and information in relevant columns. Applicant will be
held responsible for filling incomplete or incorrect information.
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2. While submitting test report complete details regarding load and machineries should
be mentioned in it, e.g. Name of the manufacturer of Motor, Kilowatt / Horse Power,
Ampere, Voltage and purpose of the motor.
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3. In case of application for transfer of Name, the Applicant shall comply with the
relevant regulations.
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4. In the case of application for transfer of name, the lieu of deceased person is required
to submit the Death Certificate as well as the succession certificate.
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5. As regards to the ownership of the land, copy of the extract of relevant revenue
records or property card along with tax bill also required to be submitted.
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6. In case the applicant is a partnership firm, necessary partnership deed and
registration certificate there of are required to submitted.
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7. If the occupier is unable to obtain “No Objection Certificate “from the owner of the
premise, he may visit company’s officer personally.
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8. In order to obtain necessary statistical data and to provide better service to the
consumer the applicant is requested to furnish the required detail property in this
requisition form.
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