DIRECTORATE: FINANCIAL SERVICES

MOKAEDI WA: MATLOTLO

APPLICATION FOR ELECTRICITY AND WATER CONNECTION (SUPPLY) - RESIDENTIAL. FORM W1

TEL: (053) 830 6111 | (053) 830 6669 WEBSITE: wwwsolplaatje.org.za PRIVATE BAG: X5030, KIMBERLEY, 8300

Unit/prop No.*

Account No.*

Deposit/Guarantee*

Date *

Surname*

Full Names*

ID No./Passport No *

Home Tel. *

Cell No.*

E-Mail Address *

Employer's Name *

Tel. No. *

Spouse's Name *

Spouse's ID No *

Cell No. *

Spouse's Employer *

Tel. No.*

Owner/Tenant *

Address where service must *

be supplied/connected *

Erf/Stand No *

Meter Nos. Water/Elec *

Complex Name, Flat No *

Suburb/Township *

Previous Address *

Reference Name*

Tel. No.*

I acknowledge in my capacity aforementioned that the services provided to me including the provision of water and electricity may be immediately terminated should I fail to pay my account with the Municipality punctually in full on due date. Furthermore, I will be liable for any legal steps against me for the recovery of an arrear account. I give express permission that should my account be in arrears in excess of 90 days that my name may be listed, without delay or reference to myself, at a recognized Credit Bureau.*

Upload Signature of Applicant*

Upload Lease Agreement/Deed Of Sale*

Upload Identity Document*