Application Form for New Connection

Type of Request

Water Connection Water and Sewerage Connection

Details of Applicant

Sewerage Connection Regularization

Govt. Organization (

lea!e tic" if it i! a Govt. Organization# provide !upporting document$

Full Name %&('loc" (etter! Onl)$ Fat*er+ ,u!-and+ .ot*er/! Name&% 012 No.%

Contact Details
3mail 1d% ,ome 4el. No% Office Details (1f 25' 3mplo)ee$ 3mplo)ee 1d% Office Name% Addre!! (ine 7% State% 2ate Of Retirement% Addre!! (ine 6% Cit)% in Code% .o-ile No%& Office No%

Property Address
in Code%& Su- localit)%& Road No% Su- localit) 7% 8illage% Societ) Name% (ocalit)%& ,ou!e No%& Su- localit) 6% Su- Colon)% 9*a!ra No% 55R Colon)

Property Details
2evelopment C*arge! aid (Su-mit (ate!t a)ment Receipt!$% ropert) 4)pe%& No. Of Floor!%& Area (1n S: m$% lot Area%& Water Connection 4)pe%& Water Connection 0!e%& 0r-an No Of 'ed!%& (For ,o!pital Onl)$ 'uilt 0p Area%&

Water

Sewerage

Other Details
referred .ode of a)ment%& referred .ode Of Communication%& No of C*ildren%

Ca!* 3mail And S.S

C*e:ue 2emand 2raft aper Format And S.S

No of Adult!%

Documents to be attached
roof of 1dentit)%& 2ocument No%& ropert) Owner!*ip 2ocument%& 2ocument No%& roof of Re!idence%& 2ocument No%&

2riving (icen!e AN Card G A Govt. Allotment (etter 2riving (icen!e

a!!port 8oter 12 Card Allotment (etter NOC from (andlord

a!!port

Ration Card

Sale 2eed Conve)ance 2eed 3lection 1dentit) Card

Bank Details
Name of t*e 'an"% Name of t*e 'ranc*% .1CR Code% 'an" Account No%

Declaration
6. 7. ;. <. >. 1 *ere-) declare t*at all t*e information furni!*ed -) me i! true to t*e -e!t of m) "nowledge and if an) di!crepancie! are found # 1 will -e re!pon!i-le for di!connection of !ervice! -) t*e 25' wit*out an) prior notice and an) ot*er legal action ta"en -) 25'. 1 declare t*at t*ere i! no di!pute on propert) and t*ere i! no !ta) from an) court of law again!t o-taining water+ !ewerage connection. 1 furt*er underta"e t*at in ca!e of an) di!pute a-out t*e owner!*ip of t*e propert) i will a-!olve 25' from an) legal -attle in t*e court of law a! t*e water connection applied for i! related to !uppl) of pota-le water and not to decide t*e owner!*ip of propert). 1 furt*er underta"e to pa) t*e c*arge! a! and w*en demanded -) 25'# and in t*e event of non=pa)ment# 25' will -e at li-ert) to di!connect t*e !ervice! -eing provided -) 25'. 1 furt*er underta"e t*at 1 *ave not ta"en ?25' 3mplo)ee Re-ate@ again!t an) ot*er remi!e+Connection.

1 Agree
Date: Place:

AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA Si nature Of Applicant:!

"nstructions to fill The #e$ Connection Application Type of Request : Select t*e t)pe of connection re:ue!t. Details of Applicant: lea!e tic" if it i! a Govt. Organization and provide !upporting document wit* t*e application form. All detail! mu!t -e provided in 'loc" (etter! eBcept 3mail 12. %irst #ame and &ast #ame: S*ould -e provided. Fir!t Name i! compul!or). %ather'(usband #ame: Applicant/! fat*er or *u!-and name !*ould -e provided and i! compul!or). Stri"e t*roug* t*e one t*at i! not applica-le. 3Bample% Fat*er+,u!-and Name% .R. S0.14 90.AR 2044A (1f fat*er/! name i! provided and vicever!a.$ )"D num-er ma) -e provided -ut i! not compul!or). Contact Details: *mail "d: S*ould -e provided in eBact ca!e. 1t i! optional. +obile #o: 1t i! compul!or) to provide mo-ile no.# a! it will -e u!ed for !ending S.S alert!. (ome Tel, #o: .a) -e provided to facilitate communication. 1t i! optional. Office #o: .a) -e provided to facilitate communication. 1t i! optional. Office Details: *mployee "D: 4*e emplo)ee 12 of t*e applicant. 4o -e provided -) 25' emplo)ee! onl). Date of Retirement: 4*e date of Retirement of t*e Applicant. 4o -e provided -) 25' emplo)ee! onl). Office #ame# Address &ine -#Address &ine .# City / State# Pin Code ma) -e provided to facilitate communication -ut i! not compul!or). Property Address: Pin Code% in code of t*e propert) mu!t -e provided. 1t i! compul!or). &ocality/ Sub locality and (ouse #o mu!t -e provided correctl). 4*e!e are compul!or). Road #o/ Sub locality -/ Sub locality ./ Sub colony/ 0illa e/ 1hasra #o/ Society #ame/ 22R colony !*ould -e provided. 4*e!e are optional. Property Details: De3elopment char es Paid: 1f development c*arge! are paid for eit*er water or !ewerage or -ot*# t*e p*otocop) of t*e related receipt mu!t -e attac*ed wit* t*e application form. Property Type% 4*i! ma) -e 4ower# Office compleB# .ot*er dair) 'oot*# .all+CinepleB# 1ndividual *ou!e# ,otel+gue!t ,ou!e# ,o!pital +Nur!ing *ome(No. of -ed! mu!t -e provided 1n t*i! ca!e$# Group ,ou!ing Societ)# Govt Flat!# 2*arma!*ala!+,o!tel!# 22A flat!# 'ungalow!# 'an:uet ,all# Apartment. An) ot*er propert) t)pe will not -e accepted. 1t i! compul!or). Refer to t*e ta-le ropert) 4)pe -elow. )rban% lea!e tic" it if t*e propert) i! pre!ent in an ur-an area. #o, of floors: .u!t -e provided. 1t i! compul!or). #o, of beds: .u!t -e provided in ca!e t*e propert) t)pe i! ,o!pital+Nur!ing *ome. Plot Area: 3nter t*e total plot area. 1t i! compul!or). Built )p Area% 1t i! compul!or) to provide t*e -uilt up area. 1t mu!t -e le!! t*an or e:ual to plot area. 4ater Connection Type% 1t i! compul!or) to provide t*e Water Connection 4)pe. 8alid value! are 2ome!tic# 1ndu!trial+Commercial# .iBed# Gov+Rain Water ,arve!ting. Refer to t*e ta-le Water Connection 4)pe -elow. 4ater Connection )se% 1t i! compul!or) to provide t*e connection u!e. (3Bample% 2el*i Fire Service# Group ,ou!ing Societ) etc.$. Refer to t*e ta-le Water Connection 0!e -elow.

Other Details: Preferred mode of payment% 4ic" t*e relevant c*ec" -oB to c*oo!e t*e preferred mode of pa)ment. 1t i! a compul!or) field. Preferred mode of communication% 4ic" t*e relevant c*ec" -oB to c*oo!e t*e preferred mode of communication. 1t i! a compul!or) field. 1f 3mail and S.S option i! !elected# t*en 3mail 1d mu!t -e provided in contact detail! to facilitate communication. #o, of Children% Num-er of c*ildren mu!t -e provided. 1t i! a compul!or) field. #o, of Adult% Num-er of adult! mu!t -e provided. 1t i! a compul!or) field. Documents to be attached:

1. 2. 3.

Proof of "dentity Doc% Attac* p*otocop) of an) one of t*e following document! and provide t*e document num-er.(8oter 12 card# Ration card# AN card# 2riving licen!e# o!t card$. Property O$nership Document% Attac* p*otocop) of an) one of t*e following document! and provide t*e document num-er.(G A# Allotment (etter# Govt Allotment (etter# Sale deed# NOC from landlord$. Proof of Residence% Attac* p*otocop) of an) one of t*e following document! (2riving licen!e# a!!port# 3lection 12 card$. 1t i! compul!or) to provide t*e document num-er of t*e attac*ed document!.

Bank Details #ame of the bank% 3nter t*e name of t*e -an". #ame of the branch% 3nter t*e name of t*e -ranc* of t*e -an". +"CR code% 3nter it! .1CR code. Bank Account #umber% 3nter t*e applicant! -an" account num-er. All field! li!ted under -an" detail! are compul!or) and mu!t -e provided correctl). Declaration% " a ree%4ic" t*e 1 Agree c*ec" -oB to accept t*e declaration. Si nature of the applicant% ut in t*e !ignature of t*e applicant in t*e -oB given. 4*i! form capture! !ome information (!a) 'illing Addre!! etc.$# w*ic* ma) -e u!ed -) 25' in future. Property Type 5*nter any of the belo$ in Property Type 6 Tower Office Comple %ot#er "air& Boot# %all!Cineple Individual House Hotel!Guest House Hospital!'ursin( Home Group Housin( )ociet& Govt Flats "#armasalas!Hostels ""$ Flats Bun(alows Banquet Hall $partment

4ater Connection Type 5*nter any of the belo$ in 4ater Connection Type6 %i ed "omestic Commercial!Industrial Gov!rain water #arvestin(

4ater Connection )se 5*nter any of the belo$ in 4ater Connection )se6 B.).*. +$,"H$'I B.).*.). 2$%1'$ Banquet #all! 3art& #all "el#i ,al Board "el#i %etro +ail Corporation "el#i Transco "el#i Transport Corporation Beaut& 3arlors Blind )c#ools Bottlin( 3lant C.3.5.". Cineple Cold )tora(eCold )tora(e Coolin( 3lant Courts ".).I.".C. "el#i "evelopment $ut#orit& "el#i Fire )ervice 8Fire )tations: "el#i Govt. Office!Central Govt. Offices "#o.i G#ats Factor& Fruit 4 7e(eta.les )tore0 +eliance )afal Govt. Hospitals! "ispensaries Govt. Institute!Colla(es! 1niversities Group Housin( )ociet& Hotel 4 Guest #ouses %alls %il6 "air& 'ort# "el#i 3ower -td. 3iaos 3olice "epartment 3rofessional Office8C$ 9 -aw&er93ropert&: 3vt. Hospitals 4 'ursin( Homes )weet )#op!Tea )tall 7e#icle )ervice )tation 5are House!Godown -a.! /0+a& 1nits %.C.". %.C.". )lums 4 ,.,. "epartment %.T.'.-. +estaurant! "#a.a )#ops )oda 5ater Factor& )oft "rin6 Factor&

Ice0Cream Factor&!Ice Factor& 3vt. Institute!Colla(es! 1niversities ,anta Flats ,eweler& %anufacturin( Factor&! +epairin( ,uice )#op 3vt. )c#ools +ailwa&s +eli(ious 3lace