New Customer

Title: * Mr Mrs Ms Master Miss Dr Rev

First name: *

Surname: *

Please indicate your preferred daytime number: * Home Work Mobile

Telephone (Home):

Telephone (Work):

Telephone (Mobile):

Email:

House name/number: *

Flat name/number (if applicable):

Road/street name: *

Town:

City:

County:

Postcode: *

Date that you moved in or took over responsibility for the water bill: * Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year 2007 2008 2009 2010 2011 2012

Meter serial No. (if known):

For household customers your meter will have 4 or 5 digits on a black or white background, followed by 2 or 3 in a red background. Include all the numbers on the black or white background and ignore all the red ones

Please supply the meter reading for when you moved in (if the property has a water meter):

How many people live in the property?: 0 1 2 3 4 5 6 7 8 9 10+

Are you responsible for paying the water service charges for the property?: * Yes No

The purpose of this form is for you to advise us that you are taking responsibility for paying the water service charges for this property, please only complete this form if the answer to this question is 'yes'.

Are you a tenant?: * Yes No

Is this property used predominantly for commercial purposes?: * Yes No

If you have any queries, please let us know in the space provided: