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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
*