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Candelaria Water District
Candeland Commercial Center
De Gala St. cor. Del Valle St. Poblacion
Candelaria Quezon
042-585-5030
DATE: __________________________
CONTROL NO. __________________
INFORMATION SHEET
(FOR RESIDENTIAL/COMMERCIAL/GOVERNMENT/INDUSTRIAL)
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_________________________ ______________________________ ___________________
SURNAME FIRST NAME MIDDLE NAME
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Complete Service Address: ________________________________________________________
______________________________________ Tel. No. ________________________________
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Office Address: _________________________ Tel. No. ________________________________
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Sex: ____________ 5. Civil Status: ___________________________
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Occupation: ________________________ 7. Citizenship: ___________________________
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Date of Birth : ______________________
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Place of Birth : __________________________________________________________________
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Name of Spouse : ________________________________________________________________
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Name of Father : ________________________________________________________________
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Name of Mother : _______________________________________________________________
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Name of Children ( if any ):
______________________________ ________________________________
______________________________ ________________________________
______________________________ ________________________________
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Type of Connection applying for:
( ) New Connection ( ) Separation (from _____________________)
( ) Reconnection ( ) Sub connection (from _________________)
( ) Others _____________________________________________________________________
Complete Address (if different from the address above)
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Status of Establishment :
( ) House ( ) Owned (house & lot) ( ) Apartment/Rented
( ) Building ( ) Stall ( ) Rented
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If establishment is rented:
Owner’s name: _____________________________________ Tel. No. ___________________
Address: ______________________________________________________________________
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Classification :
( ) Residential ( ) Commercial ( ) Industrial
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If establishment is an old building, what is the source of water?
( ) Public Faucet ( ) Neighbor’s Well
( ) Public/Private Well ( ) Neighbor’s Connection
( ) Water Vendor ( ) Connected to an existing Water System
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Nearest Concessionaire’s Account Number: ______________________________________________
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Number of People that are going to use the water service: ___________________________________
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If applicant is a former concessionaire of a Water System:
Address:___________________________________________________________________________
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Status of a former connection
( ) Disconnected ( ) With new account
( ) Vacant ( ) Others (specify):
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Authorized Representative of applicant:
Name:________________________________________ Contact No. ________________________
Address:___________________________________________________________________________
Relationship to applicant: _____________________________________________________________
CTC No. _____________________ Place: ____________________ Date: _______________
I hereby certify that all the foregoing information are true and correct, I also declare that I have no unpaid accounts with the Candelaria Water District service under my name or that of my spouse at any address. However, if it shall be found later that I (or my spouse) have unpaid accounts for water service at any address, I hereby agree that Candelaria Water District have the right to demand payment of my water service or disconnect it when no payment shall have been made by me for the aforesaid accounts after the expiration of three (3) days written notice in addition to any legal action what CWD may undertake.
_____________________________________ _____________________________________
Applicant Authorized Representative
(Signature over printed name) (Signature over printed name)
Date: ______________________ Date: _________________________
CTC No. ___________________
Place: ______________________
Date: ______________________
