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Extension of Service Application Form
NWRB application form for extension of service
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Republic of the Philippines
APPLICATION FOR EXTENSION
NATIONAL WATER RESOURCES BOARD
SERVICE
th Floor, NIA Building, EDSA, Quezon City
8
Telefax : 920-27-14
CASE NO.
PLEASE ACCOMPLISH THIS FORM IN SIX (6) COPIES
MAILING ADDRESS
WATER PERMIT NO.
CONTACT NO.
NAME OF APPLICANT
OF
SOURCE
LOCATION
CITIZENSHIP
TIN
DATE OF OPERATION
EXISTING SERVICE AREA
Subdivision :
SERVICE AREA TO BE EXTENDED:
Existing CPC/CPCN No.
Barangay :
Provisional Authority Required
Yes
Municipality :
TYPE OF UTILITY
[ ] Subdivision / HOA
[ ] RWSA
[ ] Cooperative
[ ] Bulk Water Seller/Peddler
[ ] Others
________________________
(specify)
NO. OF CONNECTIONS
a. with water meters _______________
b. w/o water meters _______________
c. meter tested
________________
c.1 tested by ________________
c.2 date tested _________________
d. for bulk seller /peddler
Average volume of water delivered in
cubic meters per day ___________
KIND OF WATER SYSTEM
[ ] Draw & Fill
[ ] Float
LIST OF DOCUMENTARY REQUIREMENTS
( ) Board resolution (for corporations and partnerships)
or special power of attorney (for single
proprietorships) authorizing the signatory to sign and
file the application
( ) Copy of Approved Water Permit/s
( ) Copy of Official Receipt/s of Annual Water Charges
( ) Copy of Latest Certificate of Potability issued by
City/Municipal Health Officer where source is
located with Results of Bacteriological, Physical &
Chemical Impurities conducted by laboratory of
DOH
( ) Plan of Water Distribution System
( ) Plan, Elevation of Cross-sectional Views of
Tank/Reservoir
( ) Plan, Elevation of Cross -sectional Views of Pump
House, Machinery & Equipment
No
FILLING FEE
a. Amount ____________
b. O. R. No. ___________
c. Date ________________
[ ] Direct Pumping
(
(
(
(
(
)
)
)
)
)
( )
( )
Latest Audited Financial Statement
Actual Balance Sheet for Water Operations
Actual Income Statement for Water Operations
List of Existing Assets in Service Subject to Return
Business Plan & Itemized List of Required Investments
for the Extension of Service
Tariff schedule to be implemented
Others
I HEREBY CERTIFY THAT THE INFORMATION GIVEN
ABOVE AND THE DOCUMENTS SUBMITTED ARE TRUE
AND CORRECT TO THE BEST OF KNOWLEDGE AND
BELIEF
SUBSCRIBED AND SWORN TO BEFORE ME ON
THIS DATE
Signature of Water Utility Representative
Notary Public / Administering Officer
