Water Delivery Service Request Form IBN Member’s Full Name:(Required)Membership Number:(Required)Date of Birth:(Required) MM slash DD slash YYYY Registered Home Address:(Required)Mobile Phone:(Required)Email Address:(Required)Community:(Required) Bellary Wakathuni Service Commencement for Financial Year(Required)2025/26You will be required to complete a new Water Bottle Delivery Service Request Form at the beginning of every financial year.Conditions: (Required)You will only be eligible to receive this service while you are residing in the Bellary or Wakathuni communities.(Required) You will only be eligible to receive this service while you are residing in the Bellary or Wakathuni communities. All empty water bottles must be placed for collection outside the residence to receive replacement bottles.(Required) All empty water bottles must be placed for collection outside the residence to receive replacement bottles. Your address and mobile number must be updated to IBN through the IBN Member Portal or by using the Update Personal Details form to continue using this service.(Required) Your address and mobile number must be updated to IBN through the IBN Member Portal or by using the Update Personal Details form to continue using this service. Declaration (Required)I declare that the information I have provided in this form is true and correct and the benefits requested are for my own use.(Required) I declare that the information I have provided in this form is true and correct and the benefits requested are for my own use. I acknowledge that I must comply with the conditions stated in this form, otherwise the service may be suspended.(Required) I acknowledge that I must comply with the conditions stated in this form, otherwise the service may be suspended. I acknowledge that I must complete a new Water Bottle Delivery Service Request Form at the beginning of each financial year. I acknowledge that I must complete a new Water Bottle Delivery Service Request Form at the beginning of each financial year. I agree that IBN may share my information with other organisations for application assessment purposes.(Required) I agree that IBN may share my information with other organisations for application assessment purposes.
