Application for a new electricity / water connection

Please fill this form to request a refund at Aqualectra. The Customer Service Department will contact you soon to confirm the details of your request.

Aanvager

Name*

Address*

Email*

Enter Email Confirm Email

Phone*

Alternative phone

Type of identification*

Id Number

Client number*

Account number*

Product*

Water/Electra

Waste Tax

Reason for your request*

Security Deposit

Amount overpaid

Financial Correction

Other

Amount*

To be paid via:*

Transfer tor Water/Electra account

Transfer to Waste Tax

Via bank

Bank*

Bank account

Documents needed in order to process your refund request:

A local Identification document (sedula, passport or driver's license)

Upload document*

Drop files here or

Max. file size: 40 MB.

Signature

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Email

This field is for validation purposes and should be left unchanged.

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Refund Form

Aanvager