In Partnership With
BHARAT SANCHAR NIGAM LIMITED
www.bsnl.co.in
FORM FOR FIBER BASED SERVICES NEW CONNECTION
Company / Organization
Individuals
(Tick appropriate box) (Please read the instructions before filling the form)
Where existing customer of BSNL?
Yes
No
If yes, provide existing telephone number:
A. Title/Name of the Customer/ (SURNAME FIRST) /Company / Firm / Organization
B. Name of the Joint Applicant, if any
C. GST No.
D. GST State
Name of Father/Husband/Group/Proprietor/Partner(s)
Nominee Name
4.
PAN/GIR NO.
Mobile Number
Complete Address where services(s) is/are required:
House No.
Street/Road/Village
Bidg/Appt.
Area/Locality/Tehsil
City/District
PIN
State
E-mail Address (if any):
Gender
Male
Female
Other
9.
Date of Birth:
Whether the applicant is a retired or working Employee of Govt./PSU/CPSU/
Yes
No
Purpose:
Residence
Business
Govt
PSU
Service Type:
Broadband
IPTV/CABLE TV
Telephone
VIDEO
Number of Connections Required:
Select Number
1
Facilities Required on Telephones
(tick whichever is required)
(please affix photograph for ISD facility):
STD
ISD
CLI
Hotline
Conferencing
Call Forwarding
Hunting Facility
Abbreviated dialing
Facilities Required on Video
(tick whichever is required)
(please affix photograph for ISD facility):
Video conferencing
Video Calls
others
Whether Telephone instrument is required
Yes
No
16.
Whether STB is required
Yes
No
Type of ONT
Type-A
Type-B
Mention the tariff package required for
[Please see various tariff packages available]
Bill Frequency
Monthly
Quaterly
Six Months
Yearly
Five Yearly
Bundled Services packages:
Payment Mode :
WILL BE PAID WITH FIRST BILL
I hereby declare that information given above is true to the best of my knowledge and I will abide by the prevailing Telegraph Act/Rules framed there under & Tariffs as amended from time to time. I am not a defaulter on account of non-payment of bills for any telecom services provided by any service provider. In the event of any dispute concerning any telecom line, apparatus or applicance, bill etc., between me/us and BSNL, the matter will be referred to the sole Arbitrator, appointed by a nominated authority in BSNL and shall be governed by the provisions of the Arbitration and Conciliation Act, 1996.
I accept the
Terms & Conditions
Submit Form
