Name: - Receipt No. F/O, S/O, D/O, W/O. :- Book No. Address :- APPLICATION FORM FOR WATER SUPPLY CONNECTION 1. Name (Industrial / Office / Institution): (In Block Letters) 2. S/O., D/O, W/O, G/S, G/D: (A rough site plan/sketch of the area where Connection is to be provided) 3. Full address (Furnish name of Leirak/Street/Lane): 4. Patta/Dag No./Art. No./Plot No. (Enclosed a photo: copy duly attested by any Gazetted Officer) 5. Ownership of the premises: 6. Municipal/Town/Ward No.: 7. Whether the applicant is having connection (Authorized/Unauthorized): 8. If authorized, Connection No. : 9. If authorized, and non-functioning, disconnected, furnish month and year if any as approved.: 10. Latest water rate cleared (Clearance receipt No. And date etc.): 11. If it is for Fresh/New Connection indicate the same: 12. Whether authorized / unauthorized no. (Indicate the nature of use): 13. If Government Employees: (a) Name in full (In block letters): (b) Designation: (c) Scale of pay: (d) Name of Department/Sub-Division: (e) Head of Department: - Signature in full and seal (In support of applicant's post held in correct) Signature of applicant Assistant Engineer, Receipt No. W/S Maintenance Rent Sub-Division, PHED, Manipur. Book No.
