Application for Connection

Note: (*) Marks filled are required.

Application Type*

Individual Application

Institute Application

Category*

WASA Zone*

Applicant's Name*

Name (বাংলা)

On Behalf of

Mobile No.*

E-mail

Application Date*

Approximate Con. Date*

I agree to the Dhaka WASA Rules and Regulations *

Enter the given letters below

Father's Name*

Mother's Name*

Spouse's Name

Telephone

Gender*

Freedom Fighter Status

Yes

Date of Birth*

NID

Birth Cert.

Passport

Freedom Fighter Certificate

Browse

Applicant's Photo*

Browse Only jpg, png, jpeg are allowed. Maximum photo size is 100 Kb.

Connection Address

House / Plot / Holding / Village*

Road / Lane

Block

Sector / Section

Area / Mohalla (recommended)

Thana*

Thana Address

Post Office*

Post Code

Latitude

Longitude

Full Address

Generated automatically; edit it when manual adjustment is needed.

Present Address Same as Connection Address

House / Plot / Holding / Village*

Road / Lane

Block

Sector / Section

Area / Mohalla (recommended)

Thana*

Thana Address

Post Office*

Post Code

Latitude

Longitude

Full Address

Generated automatically; edit it when manual adjustment is needed.

Shifting Size*

Existing Connection Account No*	Existing Tracking No.	Existing Water Connection Size*	Existing Water Meter No.*	Last bill paid date*

Only *.jpg, *.pdf are allowed. Maximum size per document is 1024 Kb or 1 MB.

Document	Select File	Preview

Mode of Payment*

Receiver's Name*

Account No.

STD-107-1310000074-4