Selikor

Container request/Petishon di kònteiner

First Name/Nòmber:(*)

Please fill in first name/nòmber

Last name/Fam:(*)

Please fill in last name/fam

Email(*)

Please fill in email

Street name/Nòmber di kaya:(*)

Please fill in Street name/Nòmber di kaya

House number/Number di kas:(*)

Please fill in house number/number di kas

Phone/Telefon:(*)

Please fill in phone//telefon

Identity number/ Number di identifikashon:(*)

Please fill in identy/identifikashon

Identity type/ Tipo di identifikashon:(*)

Please select an identification type/ tipo di identifikashon

Upload identity (PDF/JPG/HEIC):(*)

Please upload an image for identification type/ tipo di identifikashon

Account number Aqualectra/Number di kuenta(*)

Please fill in account number Aqualectra/number di kuenta Aqualectra

Upload Bill Aqualectra (PDF/JPG/HEIC):(*)

Please upload bill Aqualectra (PDF/JPG/HEIC):

Container Request/Kònteiner(*)

Please select container request/kònteiner

Upload full image (logo visble PDF/JPG/HEIC) :

Invalid Input

Upload broken part image (PDF/JPG/HEIC):

Invalid Input

Police report or motivation letter (PDF/JPG/HEIC):

Invalid Input

Upload payment receipt/komprobante di pago:

Invalid Input

I hereby authorize Selikor NV to perform all required investigations in connection with my petition. Mi ta outorisá Selikor pa hasi e investigashonnan nesesario den kuadro di mi petishon.

Authorize Selikor NV:(*)

YesNo Invalid Input

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