CUSTOMER REGISTRATION - PREPAID UTILITIES
Please complete a separate form for each property/unit to be registered.
Building/Complex Name
*
Unit Number
*
Owner/Tenant
*
Owner
Tenant
Name & Surname
*
Name
Surname
Primary Email
*
example@example.com
Secondary Email
example@example.com
Cell Number Primary
*
-
Country Code
-
Area Code
Phone Number
Cell Number Secondary
-
Country Code
-
Area Code
Phone Number
Occupation Date
*
/
Year
/
Month
Day
4 digit year, 2 digit month, 2 digit day
Date
Additional Comments
Verify Primary E-mail Address
*
Submit
Should be Empty: