*Business name* Required field

*Address line 1* Required field

*Address line 2* Required field

*Suburb* Required fieldExample: Rondebosch

*City* Required fieldExample: Cape Town

*Postal code* Required field

*Type of business* Required fieldCommercial / industrial / other - please specify

*Name* Required field

*Email* Required field

*Number* Required field

*Job title* Required fieldSpecify your current position within the business

*Does the business generate industrial effluent?* Required fieldPlease select 'Yes' or 'No'YesNo

*Does the business have an industrial effluent discharge permit?* Required fieldPlease select 'Yes' or 'No'YesNo

*Municipal account number(s)* Required fieldPlease separate each number with a comma. (Example: 1234567, 7654321, etc... )4000 characters remaining

*Municipal water supply meter number(s) * Required fieldPlease separate each number with a comma. (Example: 1234567, 7654321, etc...)4000 characters remaining

*What is the business' average municipal water intake in the past three years?* Required fieldPlease separate each year and average with a comma. (Example: 2018-10 000kl, 2017-10000kl, etc...)4000 characters remaining