ANNEX 3

APPLICATION FORM FOR MINI-GRID PERMIT

(Pursuant to S.7 and S. 8 (1) (a) of the NERC Regulations for Mini-Grids, 2016)

IMPORTANT NOTE: Your Application is incomplete unless all required documents are submitted and the application is accompanied by the appropriate processing fee.

In compliance with the NERC Mini-Grid Regulations, 2016, I am herewith certifying that I , hereby apply for a Permit pursuant S. 7 or S. 8 (1)(a) of the Mini-Grid Regulations.

1.0 PARTICULARS OF APPLICANT AND CONTACT PERSON

Name of Applicant:

Physical address:

Postal address:

Tel:

Fax:

Mobile Phone:

E-mail:

Website Address:

Name of Contact Person:

Mobile Phone of Contact Person:

E-mail for Contact Person:

2.0 LEGAL STATUS OF APPLICANT

2.1 Indicate legal status of Applicant (Tick relevant option)

(Attach Certificate of Registration, Certificate of Incorporation, Memorandum and Articles of Association, Deed of Partnership, Deed of Trust, as applicable)

3.0 NATURE OF APPLICATION

3.1 State whether Application is a fresh Application or Renewal

3.2 Existing Permits/Licences/Tripartite Contracts

Does the Applicant have an existing Permit/Licence/Tripartite Contract issued by the Commission for other systems?

If yes, state the nature of the Permit/Licence/Tripartite Contract, date issued and the Permit/Licence/Tripartite Contract number.

Date issued:

Contract number:

3.3 Refusal, Suspension or Cancellation of Permit/Licence/Tripartite Contract

Has the Applicant ever been refused a Permit/Licence/Tripartite Contract or had its Permit/Licence/Tripartite Contract suspended and/or cancelled by the Commission?

If yes, give details of the refusal, suspension, and/or cancellation.

4.0 MAIN BUSINESS ACTIVITIES OF APPLICANT

Please indicate the main business activities the Applicant is currently engaged in.

5.0 DESCRIPTION OF PROJECT

Detailed description of the project:

5.1 Site of the Mini-Grid (State, Local Government Area, Ward, Village)

State:

Local Government Area:

Ward:

Village:

(Attach title document to the land, relevant maps and drawings)

5.2 Generation

Type of system Size in kW
Generation

kW

kW

kW

kW

kW

Total: kW

Storage kW
Inverters kW

Location of the Power Plant (geographical coordinates in Degrees, Minutes, Second. e.g. Lat : 9°4'0.00"N - Long : 7°28'60.00"E):

Latitude: Longitude:

Is the Power Plant new? If no, please state number of years the plant has been in operation

Number of years of operation:

5.3 Distribution

Type of system Size of system
Lines

metres

metres

metres

metres

Total: metres

Type of Lines

Poles

poles

poles

poles

Total: poles

Transformers

No: Rating

kW

Length of distribution network (indicate geographical coordinates of four reference points)(geographical coordinates in Degrees, Minutes, Second. e.g. Lat : 9°4'0.00"N Long : 7°28'60.00"E):

Latitude of point 1: Longitude of point 1:

Latitude of point 2: Longitude of point 2:

Latitude of point 3: Longitude of point 3:

Latitude of point 4: Longitude of point 4:

5.4 Customers

Number of customers:

5.5 Revenue and Sources of Funding

Expected electricity sales [kWh/year]:

Electricity tariff [NGN/kWh or flat rate per W]:

Share Capital contribution (specify foreign or local):

Loan capital (specify source and provide evidence):

Others (specify):

6.0 DECLARATION BY THE APPLICANT

The project is not unlawful or contrary to the interest of the Federal Republic of Nigeria. hereby declare that the details stated above are, to the best of knowledge, true and correct.

Dated this day of .

THE COMMON SEAL OF THE WITHIN NAMED APPLICANT

Has hereunto been affixed in the presence of:

Sign: Sign:
Name: Name:

Sworn to this day of at

BEFORE ME

NOTARY PUBLIC/COMMISSIONER OF OATHS

ACCOMPANYING DOCUMENTATION

Please submit 2 hard copies and a soft copy of all supporting documents, including;

1. Contract between the Community Representative and Mini-Grid Operator, where applicable

2. Power station layout drawings

3. Map with position of power station and distribution network marked using indicators to distinguish single phase and three phase as well as medium voltage networks

4. Certified copy of Certificate of Incorporation, Memorandum and Articles of Association, Deed of Partnership or Deed of Trust, as applicable

5. Certified copy of Certificate of Occupancy or Lease Agreement for Project Site

6. Certified copy of Building Permit

7. Filled Standardized Spreadsheets for Tariff Calculation

Year

20

20

20

20

Number of customers

Size generation plant component

Revenue from electricity sale

Other revenue

Fuel Cost

O&M Cost

Replacement Cost

Other cost (Please specify)

Profit/Loss