SERVICE APPLICATION FORM

Date of Application: ________________________

Name (Last, Given, Middle): _______________________________________________________________
If commercial, Official Name of Establishment:_________________________________________________
Name of Authorized Representative: _________________________________________________________
Address: _______________________________________________________________________________
Landline: __________________ Mobile No: ________________________ Email: _____________________

(To be filled up by the Customer Service Assistant)

1. Is this a Senior Citizen Account? COMPLIANCE

1. Is this a Senior Citizen Account? YES NO YES NO
If Yes, the following are required:
a. Fill up application form for Senior Citizen Account
b. Office of the Senior Citizen’s Affairs (OSCA) Id Photocopy
c. Either Birth Certificate, Passport, License or any
Government issued documents (Photocopy)
2. Is this a Residential or Commercial Account? RESIDENTIAL COMMERCIAL RESIDENTIAL
If Residential, requirements are:
a. Two (2) Valid ID (Photocopy)
b. Barangay Clearance (Original)
If Commercial, requirements are: COMMERCIAL
a. Corporate SEC Certificate (Original)
b. Barangay Business Permit
c. Mayor’s Permit
d. Two (2) Valid ID of the authorized Rep.
3. Is the property owned by Applicant or Leased? OWNED LEASED
If Leased, requirements is Contract of Lease (Photocopy)
Or Authorization letter from Landlord (Original)

4. Is the connection Tapping, Plug or Across Soil Pavement? TAPPING PLUG ACROSS TYPE OF CONNECTION
If PLUG, requirement to get authorization (Original)
If ACROSS Pavement, Excavation Permit (Original)

5. Is SURVEY required? SURVEY

6. Is the customer paying in full or availing of installment or Promo?
Assessment of Fees: PAYMENT
GUARANTY DEPOSIT ______________ Full payment Full Installment
MATERIALS ______________ Php ______________
SERVICE FEE ______________
OTHERS ______________ Installment or Promo
No. of Months ________
TOTAL ______________ Php __________ / months

7. If a representative applying on behalf of the Customer? YES NO REPRESENTATIVE

If Yes, requirements are:
a. Authorization letter from customer (Original)
b. Valid Id of Representative ( Photocopy)
Note to CSA: Originals should be presented for items above where only photocopy should be submitted.
Conformed: Prepared by:
_________________________________ _________________________________
Customer’s Signature over Printed Name Customer Service Assistant
FM-CS-01