OLOOLAISER WATER AND SEWERAGE COMPANY

SafiSan Toilet Application Form

Family name: First name:
ID no.: Tel. no.:
County: Location:
Town: Area:
Plot number/address:
No. of households: No. of people living on the plot:
Remarks:
Please tick () in the table below the preferred toilets
Tick Total cost of Subsidy Amount to be paid No. of Total amount to be paid
Preferred toilet
() toilet (KSh) (KSh) by customer (KSh) toilets by customer (KSh)
1 Mamba 59,000 20,000 39,000
2 Mbilikimo (*) 25,000 No subsidy 25,000
3 Cheupe 82,000 20,000 62,000
4 Twiga 60,000 20,000 40,000
5 Ndovu 68,000 20,000 48,000
6 Kifaru 66,000 20,000 46,000
7 Kiboko 45,000 20,000 25,000
8 Tausi 45,000 20,000 25,000
9 Chui 35,000 20,000 15,000
10
*): Vault only

Please tick () in the table below the preferred mode of payment
Tick Amount Deposit Installments
Payment Option
() (KSh) (KSh) No. of installments (*) Amount per installment
Pay at once (full amount)
Pay a deposit and the rest in
instalments
Provide labour & materials and pay
remaining amount in instalments
Provide labour and materials and pay
remaining amount at once
Take a loan from a financial institution
Other (please specify)
Remarks
*): With a maximum of 5 installments See next page >>>

SafiSan Improving sanitation for better health

 The construction/assembly of the toilet. Please answer the questions below
Do you have a preferred craftsman to build your toilet? Yes No << Please tick the appropriate box
If yes, please provide the name and contact details of the preferred craftsman:
Name: Tel. no.:
Contact details: Remark:

Please tick () in the table below all documents attached to this application form
Please avail one of the following documents:
Appendix Description Tick () Remarks:
1 Copy of the National Identity Card
2 Copy of a driving license
3 Copy of a passport

Please avail one of the following documents:

Appendix Description Tick () Remarks:
4 Copy of the title deed

5 Copy of allotment letter

Please avail one of the following documents:

Appendix Description Tick () Remarks:
6 Sketch of the plot configuration
7 Other: (Specify)
In case you need further clarifications, please contact our Customer Care office

Official Information (to be filled by the water company)

Recommend the above toilet(s) to be constructed? Yes No << Please tick the appropriate box
Please provide justification:

Follow-up action required:

Remarks:

Name of officer: Official company stamp

Signature:

Designation:

Oloolaiser Water and Sewerage Company Customer Care telephone number: …….............
Trying to serve you better!

SafiSan Improving sanitation for better health