Supply of Electricity Form

Account #:

Route:

Receipt #:

Application And Agreement For Supply Of Electricity

Date Service Required*:

Note : Dates available are Mondays through Fridays, from 8:30 a.m. to 2:30 p.m. Applications received after 2:30 p.m. will be processed next business day. A request date may be changed up to two (2) working days to coincide with an existing request, or if the date is not a normal working day. Connection of new service will be done within ten (10) working days after the application was submitted. Existing meter connections will be done within two (2) working days after the application was submitted.

Individual Corporate

Individual Sections

Name*:

Mailing Address*:

Preferred language*: English Spanish Creole

Email Address*:

Telephone (Home)*:

(Work)*:

(Cell)*:

Owner Occupied*: Yes No

Occupation*:

Employed by*:

Corporate Sections

Sole Proprietorship Partnership Company Strata Corporation

Name of Business*:

Email Address*:

Mailing Address*:

Telephone(s):

Business Licence No.*:

Date of Registration*:

Director 1*:

Position 1*:

Director 2:

Position 2:

Director 3:

Position 3:

Director 4:

Position 4:

Note: Only a duly authorised officer of the ahava company has the authority to apply for electrical sarviea.

Service Requirements

Street Address where service is required: Building/House No.*:

Apartment No:

Street Name*:

District*:

Island*:

Please indicate type of Service applied for:

Permanent Supply Temporary Supply

Single Phase Three Phase

Residential Commercial Government

Please indicate type of premises* (check one): Business Private Home Apartment Water Pump Storage

Has electricity been provided previously at this address?*: No Yes

Do you own the property where service is required?*: No Yes

If you are a tenant, state landlord's name and telephone number:

Please tick to indicate if you would like to receive information on any of the following: Planned outages Energy saving tips Security lighting

Deposit:

Installation:

Amount:

Deposit transferred from Acct#:

Date:

Upload File:

the undersigned declares that the information provided on this application is true and accurate and understands that any false declaration may result in reassessment of deposit and / or disconnection of service. in case of corporate application,the undersigned confirms that i am a duly authorised officer of the company and have authority to apply for electricity service.

Having Agreed To Pay/transfer A Deposit To Fortis Tci,the Undersigned Hereby Applies For Services In Accordance With the Current Schedule Of Rates,the Customer's Handbook—terms Of Service & Other terms And Conditions Of Supply Being Fromtime to time Force Regulating the Use And Supply Of Electricity which Are On File With Fortistci, Or Any Other Superseding Schedule Governing this Class Of Service.The Undersigned Understands And Agrees To the terms Here in And Acknowledges And Agrees to the Right Of Fortis Tci to Require Security Deposits, Installations/ Connection Fee, Interest Of 2% Per Month On All Out Standing Balances And Any Other Additional Charges. Installation/connection Fees Are Non-refundable I / We Here by Agree to Payall Charges In Connection With the Installation Of Service And Supply Of Electricity and to Abide By the Rules And Regulations Of Fortistci.

I/ We Here by Acknowledge And Agree Fortistci Shall Not Be Required to Hook Up Premises Until they Receive A Certificate Of Inspection And wiring That Installation And wiring Conform To the Standards Required By the Electrical Code And Have Received the Apropriate Fees And Deposit Required By Fortistci In Accordance With Their Rules And Regulations

It Is Further Agreed that Should Fortistci Or the Undersigned terminate this Service the Undersigned Will Be Liable For All Unpaid Amounts And Authorised Fortistci to transfer Any Outstanding Amounts to Any Ofthe Undersigned's Active Fortistci Accounts.

Name*:

Signature/Date*:

Note: Tenants are required to notify FortisTCI upon termination of tenancy.

Fortis Tci application & agreement for supply of electricity

P.0. Box 132, 1030 Leeward Highway, Providenciales, Turks and Caicos Islands

Tel: 649-946-4313

Fax: 649-941-8799

Plant: 649-946-4363

Supply of Electricity Form

Official use only

Application And Agreement For Supply Of Electricity

Individual Sections

Corporate Sections

Service Requirements

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