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Name/Nòmber*

Name/Nòmber Last name/ Fam

Email/ Emeil*

Email Address Confirm Email Address

Address/Adrès*

House number/Number di kas*

Tel.*

Identification Type/ Tipo di Identifikashon*

*Of the person whose name is on the Aqualectra bill/ di e persona menshoná riba e faktura di Aqualectra

Identity number/ Number di Identifikashon*

*Of the person whose name is on the Aqualectra bill/ di e persona menshoná riba e faktura di Aqualectra

Upload valid identity/ Identifikashon bálido (PDF/JPG/JPEG/HEIC)*

Max. file size: 25 MB.

Account number Aqualectra/Number di kuenta*

Upload Bill Aqualectra/ Faktura di Aqualectra (PDF/JPG/JPEG/HEIC)*

Max. file size: 25 MB.

*not older than 6 months/ No mas ku 6 luna bieu

Do you have a doctor's declaration? / Bo tin un karta di dòkter ?*

The doctor’s declaration must be the name on the Aqualectra bill, otherwise upload a BRP (Basisregistratie Personen) document issued by the Civil Registry ‘Kranshi’ as proof of residence.
*not older than 6 months

E deklarashon di dòkter mester ta mesun nòmber di e persona menshoná riba e faktura di Aqualectra, si no ta e kaso upload BRP (Basisregistratie Personen) di ‘Kranshi’ komo prueba di residensia.
*No mas ku 6 luna bieu

Upload BRP / Doctor's declaration (PDF/JPG/JPEG/HEIC)*

Max. file size: 25 MB.

– upload BRP (basisregistratie personen) from the Civil Registry ‘Kranshi’ (not older than 6 months) as proof of residence for at least 6 people.
BRP uitreksel di 6 e persona ku ta registrá na e adrès konserní (Kranshi).

or/of

– upload a doctor’s or care institution institution’s declaration/ deklarashon di dòkter òf instansia ku ta duna kuido

Upload payment receipt/komprobante di pago (PDF/JPG/JPEG/HEIC)*

Max. file size: 25 MB.

For the registration to be processed, the registration must be complete and accurate. Otherwise, it will need to be re-registered.
Pa trata e petishon, e registrashon mester ta kompleto i korekto yená. Di otro forma mester registrá di nobo

Consent/ Aprobashon*
I hereby authorize Selikor NV to perform all required investigation in connection with my petition

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