First Name

Last Name

Telephone

Email Address

Occupation

Nationality

Work Place

ID No. & Type

Address

* * * * * Ugandan Non Ugandan *   - - Select ID Type - - National ID Passport Driving Permit Student ID Company ID Financial Card NSSF Card Voters Card Citizen ID *

Sub County/Division

Parish

LC Zone

Village

Street

Plot No

Area

Branch

Proposed Class

Includes Sewer

Purpose of Connection

* - - - Select Area - - - Adjumani Aduku Amach Anaka Apac Arua Bombo Budadiri Bugiri Bugongi Buhweju Bukakata Bukedea Bukomero Busembatya Bushenyi Busia Butebo Buwama-Kayabwe Dokolo Entebbe Fort Portal Gulu Head Quarters Hima/Rwimi Hoima Ibanda Ibuje Iganga Jinja Kabale Kabira Kabwohe/Itendero Kachumbala Kakuuto Kaliro Kalisizo Kalungu Kampala Kamuli Kamwenge Kanungu Kapchorwa Kapeeka Kaserem Kasese Kashenshero Katerera Katwe-Kabatooro Kibito/Rubona Kiganda Kigumba Kinoni Kinoni-Lwengo Kiryandongo/Bweyale Kisoro Kitagata Kitgum Kitwe Koboko Kotido Kumi Kyabugimbi Kyankwanzi Kyazanga Kyenjojo Kyotera Lira Lugazi Lukaya Luuka Luweero Lwengo Lyantonde Manafwa Masaka Masindi Mayuge Mbale Mbarara Mirama Mitooma Mityana Moroto Moyo Mpigi Mpondwe Mpugwe Mubende Muhanga Mutukula Nakaseke Nakasongola Nebbi Ngora Ntoroko Ntungamo Pader Paidha Pakwach Pallisa Parombo Rakai Rubaare-Rwentobo Rubirizi Ruhama Rukungiri Rushere Rwashameire-Kagarama Sanga Sembabule Semuto Serere Sheema Shuuku Sipi Sironko Soroti Ssanje Sunga TestArea Tororo Wobulenzi Yumbe Zirobwe * - - - Select Branch - - - * - - - Select Connection Class - - - Commercial Domestic Institutional Public Stand Pipes * Tick If Application Includes Sewer

Submit

fields marked with * are mandatory