Application form for Water/ Sewage Connection

The Liberia Water and Sewer Corporation -

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Application form for Water/ Sewage Connection

Application form for Water/ Sewage Connection

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Title(tick appropriate box) *

Mr.Mrs..Miss.Dr.Prof.

First Name

Middle Name

Last Name

Gender

MaleFemale

Company/Organization Name (if applicable):

Contact/Location Address:

Community/District:

Mobile no

Home no:

Applicant Occupation/Mode of Business:

STATUS OF APPLICANT (Tick where applicable)

Owner of PremisesTenantOccupier

No of Occupants/ family:

OWNER OF PREMISS INFORMATION

If applicant is not the owner, then provide details of the owner of the premises below:

First Name

Middle Name

Last Name

Address

Occupation

Owner Contact No.

Email Address

PREMISES USAGEResidential onlyMixed Use (residential/business)Commercial use onlyIndustrial use only

Others (specify):

TYPE OF CONNECTION APPLIED

DomesticCommercialIndustrialGovernment

Declaration

I/We, the undersigned, hereby declare that the information given on this application is true and correct, that all applicable fees and charges shall be paid and that I/we shall abide by the relevant guidelines associated with the service provided.

Name / Signature:

Date

Attested by Land-Lord:

Date

PHOTO

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