New Application
 
Water/Wastewater Service Connection Form
Important Notice: Please ensure the form is completed in full to enable us to process your application as quick and accurately as possible. Insufficient information may result in delays in the provision of connection.
 
Customer Particulars
Customer Name*   Plot No*  
Contact Person*   Full Address
Telephone Number*   Fax Number
Email Address*   Contact name of paying authority
Number of Employees Telephone No of paying authority
Escalation Contact Number Email Address of paying authority
 
Customer Requirements
Service Type Expected service commencement date
Demand Forecast
2016 2017 2018 2019 2020
Desired Pressure (bar)
  Potable Water (m3/Day)
  Processed Water (m3/Day)
  Sea Water Delivered (m3/Hr)
  Sea Water Self Extract (m3/Hr)
  Domestic Wastewater Discharge  (m3/Day)
  Irrigation Water (m3/Day)
  Treated Effluent Discharge  (m3/Day)
 
Authorized Customer Signatory Designation*  
 
Date Control Number
 
NOTE: Customer is requested to submit copy of specimen signature document of authorized personal who can sign contractual documents along with this form.
 
Upload Document*