Application for Domestic and Non-Domestic Water Connection (both Temporary and Permanent)

Details of Applicant

Unique Business Identification Number (UBIN) *

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Name *

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Designation

Father/Spouse Name

Please Tick the relevant box and furnish supportingdocument for the same

Contact Details

Mobile Number *

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Office Number

Property Address

House No.

Locality

Bye-lane

Ward No.

Dag No.

Patta No.

Mouza

Society / Colony Name

Road

Area

Nearest Landmark

Village

Holding No

Pincode

Mobile Number

Section

Type of Property as per use

Occupant of the Property

Total number of persons actually living in the property including tenants :

i. Adults

ii. Minors

Billing Address (For future use)

House No.

Locality

Bye-lane

Ward No.

Dag No.

Patta No.

Mouza

Society / Colony Name

Road

Area

Nearest Landmark

Village

Pincode

Mobile Number

Section

Type of Connection needed

Whether there is already a connection to the premisesfrom GMC,PHED or AUWSSB

Yes

No

If yes, Please specifyalong with Consumer No.

Is there any arrear fee outstanding against previouswater supply connection?

Yes

No

If yes,Please provide details

Other details

Preferred Mode of Payment

Preferred Mode of Communication

GPS Point

Declaration

a) I / We certify that the above information is correct and true to the best of my /our knowledge.

b) I / We undertake to abide by the as amended to from time to time and all other relevant orders and notifications thatwould come up from time to time in future.

c) I / We undertake to pay to all such fees / charges as are applicable for the purpose.

d) I / We undertake that in future if no bill is received by me / us by the prescribed time of the month towards user fee /charges, it would be my/our responsibility to contact the Officer-in- charge of the in the are to the collect the bill andpay up the latest updated water bill(s) against my / our premises by the date(s) prescribed in the bill(s), failing which the will have the right to take appropriate action in the matter including disconnecting the service if so needed.

e) I / We understand that a sanction for water connection to the above mentioned premises by the will be restrictedonly to water service provision and that such a sanction of house connection will have no implication in any formincluding legality on ownership of the property.

I Agree *